HEALTH  SCIENCES  STANDARD 


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(^oluinfaia  Wimbtv&it^ 
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College  of  ^(jpgicians  anb  ^uigeons 


Reference  ILibvavp 


Digitized  by  tine  Internet  Archive 

in  2010  witii  funding  from 

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http://www.archive.org/details/treatmentofpelviOOpryo 


THE  TREATMENT 


Pelvic  Inflammations 


THROUGH   THE   VAGINA 


BY 
WILLIAM  R.  PRYOR,  M.D. 

'Professor  of  Gynecology,  New  York  Polyclinic  ;   Consulting    Surgeon, 
City  (Charity)  Hospital  ;  Visiting  Surgeon,  St.  EJlizabeth 
Hospital,  New  York  City. 


WITH  no  ILLUSTRATIONS 


PHILADELPHIA  : 

W.    B.    SAUNDERS 

925  Walnut  Street 

1899 


Copyright,  1S99,    dy  W.  B.  Saunders 


^    V>  'A  .    j-v-t-<L/i,.t 


TO 

FERNAND   HENROTIN,    M.D., 

IN 

ADMIRATION   OF   HIS   SURGICAL   ABILITY 

AND   AS   A 

TOKEN    OF    THE    WARMTH    OF    MY    AFFECTION 

THIS   WORK 

IFs  irnscribeO 

BY 
THE   AUTHOR. 


PREFACE. 


This  little  book  has  been  written  at  the  request  of  the 
gentlemen  who  have  attended  my  lectures  in  the  New 
York  Polyclinic,  and  is  but  an  elaboration  of  what  I  have 
said  and  done  before  my  audiences. 

There  exists  the  utmost  confusion  in  the  profession 
regarding  the  most  successful  methods  of  treating  pelvic 
inflammations ;  and  inasmuch  as  inflammatory  lesions 
constitute  the  majority  of  all  pelvic  diseases,  the  subject 
is  an  important  one  :  Furthermore,  these  cases  are,  as  a 
rule,  emergency  cases.  An  attending  physician  cannot 
waste  time  in  studying  up  an  operation  to  be  performed, 
nor  can  he  transport  his  patient  to  a  distant  hospital. 

I  have  gone  into  pathology  only  so  far  as  will  enable 
the  operator  to  identify  the  lesions.  Some  stress  has 
been  laid  upon  the  physical  characteristics  of  the  intra- 
peritoneal lesions  as  revealed  by  vaginal  section,  for  it  is 
upon  such  an  inspection  that  the  nature  of  further  work 
must  be  based.  It  has  been  my  endeavor,  having  in 
mind  the  object  for  which  the  book  is  written,  to  put 
down  every  little  detail,  no  matter  how  insignificant, 
which  might  be  of  service. 


PREFACE. 

The  spirit  predominant  throughout  this  book  is  that 
of  an  aggressive  interference.  Yet  I  have  generally  laid 
down  also  a  palliative  method  of  treatment  for  each 
disease,  to  be  applied  where  operation  cannot  be  done 
I  have  told  what  I  think  and  do.  The  views  and  meth- 
ods of  others  can  readily  be  procured  from  the  medical 
press.  And  as  I  write  ex  cathedra^  quotations  and  refer- 
ences are  unnecessary.  Still,  it  must  not  be  imagined 
that  all  herein  contained  is  claimed  as  original.  The 
contribution  of  any  one  of  us  must  nowadays  be  small  as 
the  science  progresses,  and  I  take  pleasure  in  acknow- 
ledging my  indebtedness  to  Recamier,  Pean,  Segond,  and 
Pozzi  in  Europe,  and  to  Gaillard  Thomas,  Byford,  and 
Henrotin  in  America. 

I  have  had  great  assistance  in  the  pathological  work 
from  Dr.  F.  M.  Jeffries,  who  has  been  as  interested  in  the 
work  as  I ;  Mr.  C.  L.  Remele  has  been  most  painstaking 
in  photographing  the  specimens ;  and  to  ]\Iiss  Fanny 
Elkins  is  due  all  credit  for  the  illustrations  of  the  opera- 
tions. I  can  only  hope  that  I  may  succeed  in  directing 
the  attention  of  the  general  practitioner  to  a  surgical 
treatment  of  the  infectious  pelvic  diseases  of  women  ;  and 
if  I  do  so,  he  will  find  in  these  pages  some  hints  which 

may  be  of  service  to  him. 

William  Rice  Prvor. 


CONTENTS. 


PAGE 

Endometritis 17 

Acute  and  Chronic  Septic  Endocervicitis 20 

Acute  Gonorrheal  Endocervicitis 25 

Chronic  and  Latent  Gonorrheal  Endocervicitis 25 

Septic  Endometritis 26 

Puerperal  Infection 34 

Acute  Gonorrheal  Endometritis 47 

Chronic  Gonorrheal  Endometritis • 50 

Tubercular  Endometritis 52 

Pelvic  Inflammation 54 

Salpingitis 63 

Acute  Gonorrheal  Salpingitis 63 

Acute  Septic  Salpingitis 69 

Chronic  Septic  and  Gonorrheal  Salpingitis 72 

Tubercular  Salpingitis 89 

Pelvic  Peritonitis 90 

Tubercular  Peritonitis 104 

Inflammatory  Diseases  of  the  Ovaries 106 

Broad-Ligament  Cyst 114 

Adherent  Retropositions 117 


CONTENTS. 

PAGE 

Broad-Ligament  Abscess 121 

Diffuse  Pelvic  Sui-pikation 123 

Anesthetic •   •   •   .   .       .   .  125 

Curettage 126 

Exploratory  Vaginal  Section 136 

Conservative  Treatment 146 

Conservative  Operations  upon  the  inflamed  Adnexa  Uteri  152 

Preparation  of  Patient  for  A  Vaginal  Section     ....  161 

Vaginal  Ablation 163 

Ablation  en  Masse 180 

Ablation  by  Hemisection ....  187 

Morcellation 209 

Vagino-Abdo.minal  Hysterectomy  in  Puerperal  State  215 
After  Treatment  of  Hysterectomy  and  Vaginal  Sec- 
tion      219 

Accidents  and  Complications      223 

Secondary  Hemorrhage 227 

Intravenous  Injection  of  Nor.mal  Salt  Solution     .    .    .  229 

Instru.ments 231 

FORMUL.E       237 

Sterilization 238 

Index 241 


ENDOMETRITIS. 

General  Considerations. — Believing  that  the  phe- 
nomena of  inflammation  in  the  female  genitals  have  the 
same  general  significance  as  when  occurring  in  other 
parts  of  the  body,  and  that  pus  produced  by  such  in- 
flammation is  caused  by  the  same  pyogenic  cocci  as 
cause  inflammation  elsewhere,  my  conception  of  its  treat- 
ment is  distinctly  surgical.  In  view  of  the  ravages  which 
these  inflammations,  when  neglected,  work  in  woman's 
special  organs,  organs  important  to  her  no  more  than 
to  the  community,  organs  so  intimately  associated  with 
her  mental  and  social  as  well  as  her  physical  life,  I  am 
an  advocate  of  .energetic  methods  of  treatment.  Pyosal- 
pinx,  ovarian  abscess,  and  peritonitis  rarely  occur  except 
through  the  medium  of  the  uterus.  The  excepted  cases 
where  the  intestinal  tract  is  to  blame  for  the  pelvic  lesions 
are  so  rare  that  they  but  emphasize  the  rule.  Such 
being  the  case,  the  importance  of  properly  treating  en- 
dometritis is  apparent. 

But  while  we  combat  their  diseases,  the  special  func- 
tions of  the  organs  must  be  considered,  and  in  our  en- 
deavors to  check  an  invasion  from  without  we  must  so 
act  as  to  do  the  least  damage  to  that  peculiar  membrane, 
the  endometrium,  whose  function  it  is  to  produce  the 
decidual  cell.  Therefore  I  advocate  the  use  of  large 
quantities  of  mild  antiseptics  as  washes,  agents  which  by 
their  bulk  ensure  cleanliness,  and  by  their  innocuous- 
ness  do  not  damage  the  tissues.  Conversely,  I  am  op- 
posed to  the  use  of  small  quantities  of  powerful  escharotic 
antiseptics,  such  as  carbolic  acid,  zinc  chlorid,  etc.  The 
greater  the  degree  of  infection  within  a  cavity,  the  less 
the  indication  for  strong  antiseptics ;  for  these  but  de- 
2  17 


i8  PELVIC    INFLAMMATION. 

stroy  tissue  in  a  locality  whose  vitality  is  already  damaged 
by  inflammation,  and  by  the  slough  caused  they  produce 
the  most  propitious  culture  medium  for  the  germs  not 
removed.  Dead  tissue  must  be  cast  off  by  suppuration. 
If  after  curettage,  for  example,  in  chronic  purulent  (sep- 
tic) endometritis,  the  raw  surfaces  be  painted  with  car- 
bolic acid  or  even  iodin,  the  intra-uterine  packing  of 
iodoform  gauze  will  be  followed  by  temperature.  Why? 
Because  the  superficial  slough  produced  by  the  applica- 
tion is  not  removed  by  the  dressing,  retention  results, 
and  recovery  is  accompanied  by  fever.  But  if  after  a 
clean  curettage  the  uterus  be  irrigated  with  boric  acid 
solution,  the  gauze  dressing  protects  the  uterus  while 
the  endometrium  is  in  process  of  repair,  and  the  conva- 
lescence is  afebrile.  Sterility  commonly  follows  one 
method,  conception  can  be  expected  after  the  other. 
That  is,  the  function  of  the  uterus  is  partially  destroyed 
by  one,  while  its  return  to  a  physiological  state  is  pro- 
moted by  the  other. 

So  far  as  the  treatment  of  endometritis  is  involved,  the 
physician  is  concerned  clinically  with  whether  it  is  puru- 
lent or  no)i-puruIcnt.  If  purulent,  applications  to  the 
endometrium  are  contra-indicated :  if  non-purulent,  appli- 
cations may  be  used.  But  great  care  must  be  exercised 
lest  the  innocent  form  be  converted  into  the  virulent 
type.  Whenever  pus  is  discharged  from  the  uterus,  the 
woman's  position  is  just  the  same  as  that  of  any  other 
patient  who  has  a  purulent  discharge  from  some  other 
part  of  the  body;  it  is  a  surgical  case.  With  our  present 
precise  methods  of  examination,  and  in  view  of  our  ability 
to  do  clean  work  under  all  circumstances,  there  no  longer 
exists  any  excuse  for  employing  the  opium,  poultice,  and 
douche  treatment  of  a  spreading  infection.  The  moment 
a  physician  sees  pus  escape  from  the  uterus  his  anxiety 
must  begin,  and  the  instant  an  extension  to  the  adnexa 
or  peritoneum  sets  in,  his  responsibility  becomes  great. 
A  woman  who  has  once  had  tubal  or  peritoneal  disease 
occupies  an  unfortunate  position  in  society;  she  has  be- 
fore her  all  her  life  a  possibly  dangerous  operation.     For 


ENDOMETRITIS. 


19 


a  man  to  sit  quietly  by  and  see  this  condition  brought 
about  without  attempting  to  check  the  infection  is  to 
assume  a  responsibility  before  his  patient  and  the  pro- 
fession which  I  always  refuse.  Be  careful  lest  you  con- 
vert the  simple  milky  discharge  of  the  nullipara  into  a 
purulent  one  by  caustics ;  and  be  again  careful  lest  you 
promote  an  extension  of  a  purulent  disease  ;  finding  the 
one,  let  it  alone ;  detecting  the  other,  check  it  instantly. 

We  may  well  ask  the  simple  question,  why  do  women 
have  peritonitis  so  much  more  often  than  men  ?  The 
answer  comes  with  the  question.  If  then  the  open  in- 
fected uterus  is  to  blame,  why  not  attack  its  filth  first  ? 
Here  the  infection  began,  and  from  this  source  the  fire 
is  fed.  Combat  it  here.  To  me  it  is  as  rational  to  incise 
an  axillary  bubo  and  neglect  the  felon  which  causes  it, 
as  to  remove  acutely  inflamed  tubes  and  ignore  the 
causative  endometritis.  This  I  can  say  to  the  man  who 
first  sees  these  cases,  that  whereas  we  now  do  many 
hysterectomies  for  pelvic  inflammation,  but  few  would 
require  it  if  the  uterine  inflammation  were  first  energeti- 
cally and  properly  treated. 

It  must  not  be  understood  from  what  I  have  said  that 
I  believe  all  forms  of  endometritis  are  caused  by  patho- 
genic germs.  Undoubtedly  simple  endometritis  may 
be  found  frequently  to  be  of  purely  hematogenous  origin, 
and  such  a  type  may  have  the  characteristics  com- 
mon to  those  forms  due  to  germs,  except  the  production 
of  pus.  Such  an  endometritis  being  purely  local,  never 
inducing  complications  so  long  as  it  maintains  its  type, 
never  causing  metastases,  is  amenable  to  non-surgical 
measures.  The  leucorrhea  of  the  young  girl  is  relieved 
by  tonics  and  a  change  of  climate;  that  of  the  gouty 
woman  is  cured  by  agencies  directed  against  the  diathe- 
sis, etc.  Of  these  states  of  the  endometrium,  I  will  not 
treat.  The  neglect  to  draw  clearly  the  distinction  be- 
tween those  changes  in  the  uterus  which  are  hematoge- 
nous and  those  produced  by  germs  has  led  to  much 
confusion  among  gynecologists  regarding  the  various 
methods  of  treatment.     It  is  in  the  first  class  that  appli- 


20  PELVIC   INFLAMMATION. 

cations  to  the  endometrium  arc  permissible.  I  can  but 
repeat  the  caution  I  gave  above,  for  it  is  exceedingly- 
easy  by  means  of  a  filthy  sound  or  dilator  to  change  one 
type  without  complications  into  that  other  virulent  form 
which  is  the  starting  point  of  processes  of  the  most  de- 
structive kind. 

Forms  of  Endome'jritis. 

^^P^^^',       ,  ]  Of  the  Cervix; 

(jionorrheal,  > 

Tubercular,  J  ^^  ^^'^  ^^''P"-^- 


ACUTE  AND  CHRONIC  SEPTIC  ENDOCERViaTIS. 

The  dense,  firm  tissue  of  the  cervix  has  normally  great 
resistant  power  against  all  the  pyogenic  cocci  except 
the  gonococcus.  Lined  as  it  is  by  a  membrane  well 
supplied  with  racemose  glands,  it  presents  the  charac- 
teristics of  other  structures  so  formed.  In  the  mature 
woman  septic  endocervicitis  does  not  often  exist  alone, 
but  in  young  women  it  is  very  common  (Fig.  I.)  Most 
often  it  is  found  to  be  co-existent  with  a  more  or  less 
severe  type  of  corporal  endometritis.  Where  the  gono- 
coccus is  the  cause  of  the  inflammation,  endocervicitis 
very  frequently  exists  alone. 

Symptoms. — In  the  acute  stage,  beyond  a  sense  of 
weight  in  the  pelvis,  little  discomfort  is  felt.  There  is  a 
profuse  purulent  discharge  from  the  cervix,  tenacious 
and  hard  to  remove.  But  in  some  cases  no  discharge  is 
noticed  other  than  one  normal  to  the  parts,  the  patho- 
genic germs  being  quiescent.  Upon  examination  we 
find  the  cervix  congested  and  in  very  acute  stages, 
bleeding  upon  the  slightest  touch.  The  follicles  project 
from  the  surface  as  red  papillae  and  give  to  the  cervix  the 
appearance  of  being  "  eroded  "  or  "  ulcerated."  (Figs.  2,  3). 
In  more  chronic  cases  the  Nabothian  follicles  become  af- 
fected ;  certain  of  the  typical  glandular  follicles  become 
closed,  and  they  too  form  cysts.  This  process  of  in- 
flammation may  be  so  general  and  extensive  that  the 


Fig.  2. — «,  b,  simple  papillary  erosion;  c,  follicular,  slightly  enlarged  (Pozzi). 


ENDOMETRITIS. 


2r 


cervix  becomes  riddled  with  cysts,  constituting  cystic 
degeneration.  In  such  cases,  in  addition  to  a  possible 
folliculitis,  we  have  presented  the  appearance  of  slight 
rounded  elevations  projecting  upon  the  vaginal  face  of 
the  cervix  and  covered   by  epithelium.      Upon  pricking 


■  Fic;.  I. — Transverse  section  through  the  upper  part  of  the  cervix,  showing 
.  the  entire  mucous  membrane.  The  central  cavity  is  the  cervical  canal :  b,  b, 
internal  surface  of  mucous  membrane,  presenting  small  folds,  superficial 
glandular  depressions,  and  large  incisions  of  the  arbor  vitse  {d);  ^,g,  deep 
glands ;  a,  a,  ovules  of  Naboth ;  m.,  in,  musculartissue  of  the  uterine  wall 
(Cornil). 

one,  either  a  clear,  glairy  fluid  escapes,  or  else  a  drop  of 
pus  is  squeezed  out,  leaving  a  depression.  The  condi- 
tion obtains  not  only  upon  the  surface,  but  also  through- 
out the  entire  cervical  structure.  When  the  mouths  of 
the  glands  within  the  cervix  become  closed,  they  may 


22 


PELVIC    INFLAMMATIOM. 


continue  to  secrete,  and  the  enlargement  becomes  more  or 
less  pedunculated,  forming  a  polypus  (Fig.  4).  Even  in 
cases  presenting  no  symptom  other  than  enlargement,  a 
positive  diagnosis  of  the  cause  can  not  be  determined  with- 
out the  microscope.  In  collecting  the  secretion,  a  curette 
should  be  used  and  not  a  swab,  as  pressure  upon  the 
glands  is  necessary  to  dislodge  their  contents.     Where 


Fk;.  3. — Simple  follicular  cysts  of  the  cervix  (Auvard). 


cystic  degeneration  is  present,  emotional  disturbances 
are  common.  Tlie  presence  of  any  purulent  discharge 
calls  for  not  only  a  digital  exajiiination,  but  an  ocular  one 
as  zvell. 

Diag-nosis. — Endocervicitis  alone  does  not  produce 
the  intense  pain,  fever,  and  the  uterine  tenderness  which 
accompany  purulent  endometritis.  The  erosions  of  en- 
docervicitis can  scarcely  be  mistaken  for  either  the  ulcera- 
tive or  nodular  cancer  of  the  cervix;  but  a  badly  cystic 
cervix  will  sometimes  closely  resemble  nodular  cancer. 
The  patient's  age  may  still  further  render  the  case  sus- 
picious. If  cancer  exist,  a  pair  of  blunt  bullet  forceps 
made  to  grasp  the  questionable  cervix  will  tear  out  easily 
and  produce  profuse  bleeding.  In  cystic  degeneration 
there  is  greater  strength  in  the  tissues,  and  pulling  the 
forceps  through  such  a  cervix  is  very  difficult  and  will 


ENDOMETRITIS. 


23 


evacuate  a  number  of  cysts.  It  is  commonly  easy  to 
push  a  Simpson's  sound  into  a  cancer  nodule.  Cystic 
degeneration  is  apt  to  be  general  throughout  the  cervix, 
whereas  nodular  cancer  is  at  first — the  only  period  at 
which  it  is  possible  to  mistake  it  for  any  other  condition 


Fig,   4. — Mucous   polypi   from   the   interior  of    the    cervix   and   upon    the 
surface  (Pozzi). 

— limited  to  one  portion  of  the  cervix,  and  even  later  on 
in  the  disease  one  nodule  is  prominent  over  the  others. 
The  nodules  of  cancer  are  larger  than  the  cysts  and  have 
more  injected  and  more  vascular  edges.  It  must  not  be 
forgotten  that  both  cancer  and  cystic  degeneration  may 
exist  in  the  same  subject.  Should  the  diagnosis  be  still 
further  in  doubt,  a  piece  should  be  amputated  and  sub- 
mitted to  a  pathologist  for  examination. 


24 


PFXVIC    INFLAMMATION. 


Trcatinoiit. — Endocervicitis  should  be  vigorously 
treated.  The  best  application  is  tincture  of  iodin,  a 
powerful  diffusible  antiseptic  and  astringent.  A  silver 
applicator  is  wrapped  with  cotton  and  dipped  in  the 
iodin.  It  is  then  passed  to  but  not  through  the  internal 
OS.  The  cervical  speculum  should  not  be  used.  The 
cervix,  if  markedly  congested,  should  be  punctured  with 
a  scalpel  in  a  half  dozen  places  to  produce  bleeding,  and 
this  should  be  promoted  by  hot  vaginal  douches  of  ^  ot 
I  per  cent.  lysol  every  four  hours,  continued  for  one  day. 
The  iodin  is  to  be  applied  every  other  day  except  in 
gonorrhea,  and  then  once  each  day.  Usually,  in  a  few 
days  this  treatment  will  subdue  all  symptoms  of  inflam- 
mation. If  the  cervix  be  the  seat  of  polypi,  or  is  hyper- 
trophied  or  markedly  cystic,  it  should  be  amputated  after 
all  acute  symptoms  have  subsided.  During  treatment 
coition  is  prohibited. 

The  latency  of  gonorrlieal  and  septic  endocervicitis  and 
the  fact  that  either  form  of  infection  may  exist  witJwiit  pro- 
ducing patliological  discharges  must  be  constantly  before 
the  physician  zvhen  he  wishes  to  nse  the  sound,  or  to  operate 
upon  the  cervix.  In  any  case  giving  the  history  of  a  pre- 
vious purulent  discharge  or  any  form  of  pelvic  inflamma- 
tion, the  introduction  of  the  sound  through  the  unster- 
ilized  cervical  canal  is  positively  contra-indicated.  The 
application  of  tincture  of  iodin  to  the  cervix  will  super- 
ficially sterilize  it  for  the  use  of  the  sound.  If  cystic 
degejieration  is  present  the  cysts  should  be  pricked  and 
the  pits  touched  with  tr.  of  iodin.  If  cervical  polypi  are 
present  they  may  be  removed  without  narcosis  by  using 
cocain.  An  applicator  wrapped  with  cotton  is  dipped  in 
lO  per  cent,  cocain  solution  and  passed  into  the  cervix. 
It  is  left  there  five  minutes.  The  polypus  is  then  seized 
by  Luer's  forceps  and  twisted  off  The  bleeding  is  usu- 
ally trivial.  If  of  moment,  the  cervix  is  steadied  by 
bullet  forceps  and  iodin  painted  over  the  oozing  surface, 
after  which  the  cervix  and  vagina  are  packed  for  twenty- 
four  hours  with  iodoform  gauze.  These  polypi,  although 
not  of  cancerous  nature,  are  apt  to  recur,  and  it  is  there- 


ENDOMETRITIS 


25 


fore  advisable  to    amputate    the    cervix   by    Shrocder's 
method  if  more  than  one  polypus  is  present. 

ACUTE  GONORRHEAL  ENDOCERViaTlS. 

The  gonococci  lie  upon  the  surface  of  the  membrane 
and  deep  in  the  glands.  Of  all  acute  forms  of  endocer- 
vicitis,  this  is  the  most  common. 

Sjanptoms. — These  are  the  same  as  those  of  septic 
endocervicitis.  With  gonorrheal  infection  there  is  apt 
to  be  more  erosion  and  the  production  of  pus  is  greater. 

The  diag-iiosis  is  based  upon  finding  the  gonococcus  in 
the  discharges  and  upon  the  presence  of  symptoms  of 
gonorrhea  in  other  parts  of  the  genital  tract  or  urethra. 

Treatment. — Strong  solutions  of  silver  nitrate  (5j  to 
fSj)  may  be  applied  daily  so  long  as  acute  symptoms 
exist,  but  the  tincture  of  iodin  and  local  blood-letting 
have  given  me  such  excellent  results  that  I  usually 
employ  them.  A  slender  applicator  is  wrapped  with 
cotton  and  dipped  in  the  solution.  It  is  then  inserted 
into  the  cervix  up  to  the  os  internum.  This  application 
is  made  every  day  or  two  until  the  discharge  of  pus 
ceases.  The  vagina  should  be  douched  with  bichlorid, 
1 :  10,000,  every  three  hours.  The  complications  result- 
ing from  an  extension  of  the  infection  are  gonorrheal 
endometritis  and  salpingitis.  The  cervix  infected  by  the 
gonococcus  should  never  be  irrigated  lest  the  cocci  be 
washed  higher  into  the  more  important  uterine  cavity. 

CHRONIC  AND  LATENT  GONORRHEAL 
ENDOCERVICITIS. 

This  condition  is  more  common.  A  woman  may  have 
the  gonococcus  infect  her  cervix  and  pass  through  a  mild 
attack  of  "  yellow  leucorrhea  "  without  disagreeable  sub- 
jective symptoms.  Absolutely  all  discharge  may  cease, 
and  yet  she  be"  in  a  condition  to  infect  others  and  to 
become  acutely  inflamed  if  the  cervix  be  subjected  to 
traumatism.     I  examined  one  hundred  clinic  cases  show- 


26 


PELVIC   INFLAMMATION. 


ing  no  discharge  of  pus  from  the  cervix.  The  gonococ- 
cus  was  found  in  the  cervix  in  twenty-two.  This  fact  of 
latency  explains  those  accidents  which  follow  the  rough 
use  of  the  sound  or  operations  upon  the  cervix.  The 
cervix  must  be  scraped  with  a  small  curette  in  securing 
its  discharge,  for  the  cocci  lie  deep  in  the  glands. 

The  symptoms  and  treatment  are  the  same  as  for 

septic  endocervicitis.  In  fact 
the  clinical  picture  of  both  con- 
ditions is  much  the  same  and 
bacteriological  examination 
will  alone  differentiate  them. 

After  repeated  attacks  of 
cervical  inflammation  the  tis- 
sues about  the  cervix  become 
infiltrated  by  connective  tissue 
elements,  and  as  a  result  the 
cervix  becomes  more  or  less 
fixed  at  the  vaginal  vault.  This 
pericervical  thickening  and 
contraction  is  more  marked 
in  the  condition  described  as  genital  sclerosis  (Fig.  5). 


Fig.  5. — Gonococci  in  the  secre- 
tion from  the  urethra  in  fresh  gon- 
orrhea: a,  mucus  with  separate 
cocci  and  diplococci;  b,  pus  cells 
with  diplococci ;  c,  pus  cells  without 
diplococci ;    X  7°°  diam. 


SEPTIC  ENDOMETRITIS. 

Acute  Septic  Endometritis. 

Septic  inflammation  of  the  lining  membrane  of  the 
body  of  the  uterus  is  not  often  found  to  exist  in  cases 
which  have  not  recently  been  pregnant  or  which  do  not 
have  neoplasms,  as  polypi,  within  the  uterus ;  but  the 
condition  existing  as  a  chronic  state  may  at  any  time  be 
converted  into  an  acute  one  by  any  traumatism  inflicted 
upon  the  uterus.  The  causative  germs  are  staphylococci 
and  streptococci  (Figs.  6,  7  and  8). 

Symptoms. — There  may  be  a  chill,  but  this  is  not 
usual.  From  twelve  hours  to  three  days  after  the  infec- 
tion the  patient  begins  to  have  a  sense  of  fulness  in  the 
pelvis.     In  a  {q\^  hours  this  increases  to  a  positive  pain, 


ENDOMETRITIS. 


27 


and  in  aggravated  cases  spasmodic  contractions  of  the 
uterine  muscle  follow  ("  womb  cramps  ").    With  the  first 


■%'^^^i&i&   mm 


Fig.  6. — Normal  mucous  membrane  of  the  uterus  during  menstruation.  A 
preparation  of  the  layer  removed  by  curette  during  menstruation.  The  figure 
reproduces  the  upper  third  of  the  membrane.  There  are  small  extravasations 
here  and  there  ;  in  the  deeper  parts  is  almost  normal  interglanduiar  tissue,  the 
glands  being  somewhat  more  sinuous  than  usual.  The  blood-vessels  are  full ; 
the  upper  layers  are  partly  normal,  partly  infiltrated  with  blood  cells ;  the  epi- 
thelium, for  the  most  part  preserved,  is  here  and  there  raised  from  its  seat  and 
covered  with  altered  blood  cells  ;  hemorrhage  into  the  glands  in  places ;  no 
appearance  anywhere  of  the  fatty  degeneration  described  by  certain  authors 
(Williams,  Kundrat,  Engelmann).  It  is  very  likely  that  sometimes  during 
menstruation  part  of  the  mucous  membrane  is  destroyed  (Leopold,  Wyder), 
and  that  there  is  no  such  desquamation  at  other  times  (Moericke).  This 
figure  shows  that  the  different  changes  may  be  simultaneous,  and  that  there 
is  great  diversity  m  the  process  :  a,  Normal  uterine  tissue  formed  of  numerous 
rounded  embryonal  cells  ;  i,  same,  infiltrated  with  blood  corpuscles  to  a  con- 
siderable depth;  c,  dilated  vessels,  full  of  blood;  d,  intact  uterine  mucosa;  e, 
place  where  it  has  become  detached  ;  /,  longitudinal  section  of  a  gland  ;  the 
epithelium  near  its  mouth  has  disappeared  ;  £-,  dilated  glands ;  k,  gland  whose 
lining  epithelium  has  become  detached ;  i,  normal  deep  glands  ;  j,  mucous 
membrane  raised  by  infiltration  of  blood  (Pozzi). 

symptom  there  takes  place  a  slight  rise  in  the  tempera- 
ture, and  the  evening  temperature  is  usually  one  degree 


28 


PELVIC   INFLAMMATION. 


higher  than  the  morning.  Or,  there  may  be  no  fever. 
The  subjective  symptoms  rapidly  increase  until  within  a 
few  hours  the  discharge  begins.  At  first  this  is  muco- 
purulent, but  generally  by  the  end  of  the  first  day  it  has 
become  distinctly  purulent  and  may  be  tinged  with  blood. 
The  woman  takes  to  bed,  so  great  is  the  suffering,  and 


Fig.  7. — Acute  endometritis.  Slightly  enlarged  view  of  entire  mucosa  :  a, 
Superficial  layer  formed  of  more  or  less  altered  tissue,  infiltrated  with  coagu- 
lated blood  ;  b,  round-celled  embryonal  tissue ;  c,  zone  in  which  these  cells  are 
especially  numerous  ;  d,  large  dilated  and  varicose  vessels  gorged  with  blood  ;  e, 
lymph  spaces  ;  /,  transverse  sections  of  glands  ;  g,  glandular  cul-dc-sac  (PozziJ. 

soon  after  the  onset  the  pain  has  become  general  over 
the  pelvis.  If  the  infection  occurs  at  the  menstrual  time, 
the  flow  is  increased  considerably  and  the  blood  is  apt 
to  clot. 

Upon  examination  the  suprapubic  region  is  sensitive. 
The  finger  introduced  into  the  vagina  passes  without 
evidence  of  suffering  until  the  cervix  is  touched,  when 
the    patient   will  jump    and    utter  an    exclamation.      If 


ENDOMETRITIS. 


29 


bimanual  examination  is  possible,  the  entire  uterus  will 
be  found  exceedingly  sensitive  and  more  or  less  fixed  in 
the  pelvis.  This  fixity  is  not  due  to  peritonitis  or  tubal 
disease  in  all  cases,  but  to  a  tonic  contraction  in  the  liga- 
ments supporting  the  organ.  Examining  with  the  specu- 
lum, a  rope  of  mucopus  is  seen  hanging  from  the  cervix. 


Wi 


V 


Fl(5.   8. — Microscopic  section   of  tlie  normal   endometrinm,   sliowing  the 
utricular  glands  extending  into  the  muscular  tissue  (Beyea). 

The  cervix  is  deeply  congested,  and  in  cases  due  to  infec- 
ting plastic  operations  upon  the  cervix  the  tissues  may 
be  in  a  sloughing  condition.  Wherever  there  has  been 
a  break  in  the  cervical  or  vaginal  tissues  there  will  be 
found  a  patch  of  gray  false  membrane.  This  is  only 
occasionally  the  case  in  staphylococcus  infection,  but 
almost  invariably  in  streptococcus  inoculation.  The 
cervix  may  bleed  upon  the  slightest  touch ;  it  is  soft  and 
the  OS  more  open  than  normal.  After  existing  for  a  few 
days,  the  case  either  presents  the  symptoms  of  some 
complication  or  the  acute  symptoms  subside.  In  the 
latter  event,  after  three  days  the  woman  feels  better,  the 


3° 


PELVIC   INFLAMMATION. 


discharge  diminishes,  and  within  a  week  she  is  able  to  be 
up.  TJiis  happy  result  is  not  often  seen  in  untreated 
cases,  and  in  those  cases  which  do  recover  without  com- 
plication, the  inflammation  usually  persists  as  a  chronic 
process. 

Differeiitial  Diag-nosis. — There  is  usually  a  history 
of  traumatism,  such  as  an  operation  or  invasion  of  the 
inside  of  the  uterus  or  of  abortion  or  labor.  This  is 
lacking  in  gonorrhea.  Again,  in  gonorrhea  there  is  to  be 
found  usually  some  other  manifestation  of  that  disease, 
as  urethritis  or  Bartholinitis,  or  vulvitis.  Endoccrvicitis 
does  not  present  the  grave  symptoms  which  are  due  to 
endometritis.  Acute  tubal  and  ovarian  inflammation  and 
peritonitis  give  signs  in  the  peri -uterine  tissues  which  are 
not  found  with  uncomplicated  endometritis. 

Sequelee. — The  most  common  sequela  of  a  neglected 
septic  endometritis  in  a  nuUiparous  uterus  is  salpingitis. 
The  peritoneum  may  become  involved,  and  from  this 
point  the  infection  may  spread  so  as  to  implicate  the 
ovaries  and  general  pelvic  peritoneum.  The  uterus  may 
be  retroposed  or  become  so,  and  will  become  adherent 
in  its  displaced  position. 

Treatment. — Non-operative. — If  the  condition  fol- 
lows a  septic  plastic  operation,  all  sutures  should  at  once 
be  removed  and  the  wound  painted  with  tincture  of  iodin. 
No  vaginal  dressing  should  be  applied,  but  the  freest 
possible  exit  to  the  pus  afforded.  Warm  vaginal  douches 
of  one-half  of  one  per  cent,  lysol  or  three  per  cent,  boric 
acid  are  to  be  used  every  three  hours.  Attempts  should 
always  be  made  to  wash  out  the  uterus.  The  ease  with 
which  this  may  be  done  is  dependent  upon  the  state  of 
the  cervical  canal.  The  patient  is  placed  in  Sims'  posi- 
tion and  the  perineum  drawn  back.  The  operator  and 
his  material  are  sterilized  (see  sterilization).  The  cervix 
is  sterilized  by  means  of  an  application  of  iodin  (see  endo- 
ccrvicitis), steadied  by  a  pair  of  blunt  bullet  forceps,  and 
the  direction  of  the  uterine  canal  found  by  a  sound.  A 
Fritsch-Bozeman  catheter  to  suit  the  size  of  the  cervical 
canal  is  then  introduced  up  to  the  fundus  (Fig.  9).  No  vio- 


J' 


\\     I 

\\       * 


Fig.  9. — Irrigating  the  uterus  through  a  double-current  catheter. 


ENDOMETRITIS. 


33 


lence  is  to  be  used.  The  irrigator  (see  sterilization)  should 
be  five  feet  above  the  patient.  At  first  a  quart  of  Thiersch 
solution  is  allowed  to  flow  through  the  catheter,  to  be 
followed  by  at  least  four  quarts  of  a  three  per  cent,  solu- 
tion of  boric  acid  crystals.  The  treatment  varies  accord- 
ing to  the  progress  of  the  case.  Often  one  such  washing 
will  suffice  to  subdue  acute  symptoms  ;  but,  if  after  wait- 
ing twelve  hours,  the  patient  is  not  markedly  better,  the 
washing  is  to  be  repeated.  The  irrigations  are  to  be  made 
once  or  twice  daily,  the  physician  being  governed  by  the 
amount  of  discharge  and  the  symptoms.  An  ice-bag 
should  be  worn  over  the  pubes  continuously  until  con- 
valescence begins.  The  sense  of  weight  and  even  the 
inflammation  are  materially  lessened  by  local  blood- 
letting. This  is  done  by  superficial  stabs  into  the  cervix 
with  a  bistoury. 

After  the  acute  symptoms  subside,  the  case  is  to  be 
treated  as  are  cases  of  chronic  endometritis.  The  pain 
is  sometimes  unbearable.  In  vigorous  individuals  phena- 
cetin,  grs.  v,  with  codein,  gr.  ss.,  may  be  administered 
and  repeated  in  two  hours  if  needed.  Or  a  rectal  sup- 
pository of  extract  of  opium  and  ext.  belladonna,  each 
gr.  ss.,  may  be  given.  But  in  administering  these  drugs 
the  sympt  ms  are  so  masked  that  the  extension  of  the 
disease  may  not  be  appreciated,  and  it  is  therefore  advis- 
able to  avoid  them.  It  is  not  necessary  to  purge  these 
patients;  merely  normal  stools  are  all  that  are  required. 
The  rectum  must  be  kept  empty. 

If  after  two  days'  treatment  the  local  and  general  symp- 
toms do  not  improve,  an  extension  to  theadnexa  or  peri- 
toneum is  to  be  suspected.  During  the  treatment,  light 
vaginal  tampons  of  iodoform  gauze  may  be  used  instead  of 
the  douches,  where  the  uterus  is  subjected  to  jarring  by 
vomiting. 

Surgical  Treatment. — In  view  of  the  possible  exten- 
sion of  the  infection  to  the  peritoneum  and  adnexa,  it  is 
important  to  check  the  disease  at  once.  This -can  be 
done  with  certainty  by  a  properly  performed  curettage 
(see  curettage).     The  responsibility  resting  upon  the  at- 

3 


34 


TELVIC   INFLAMMATION, 


tendant  is  so  great  that  he  should  in  all  cases  place  him- 
self clearly  on  record  with  his  patient  and  compel  her  to 
assume  responsibility  for  any  complication  which  may 
follow  a  neglect  to  clean  out  an  infected  uterus.  If  the 
curettage  has  been  improperly  performed  or  done  too 
late  to  check  an  extension  to  the  tubes  and  peritoneum, 
it  will  be  necessary  to  open  the  cul-de-sac  and  treat  the 
adnexa  (see  cul-de-sac  operation). 

PUERPERAL  INFECTION. 

This  is  an  infection  occurring  during  the  first  four 
weeks  after  delivery.  Infection  ensuing  after  that  time 
is  not  puerperal  infection,  but  is  merely  endometritis  in 
a  large  uterus ;  and  treatment  applied  to  an  infected 
uterus  after  the  puerperal  month  is  not  the  treatment  of 
a  puerperal  uterus,  although  the  lesions  may  be  the  re- 
sult of  a  puerperal  infection.  Therefore,  curettage  or 
hysterectomy  done  some  six  weeks  after  delivery  is  not 
to  be  considered  as  having  been  applied  for  puerperal 
fever.  The  condition  of  the  tissues  one  week  and  six 
weeks  after  labor  are  so  different  that  the  lesions  pro- 
duced are  different,  and  the  dangers  from  a  hysterectomy 
at  the  two  intervals  are  about  as  fifty  per  cent,  to  five  per 
cent.  Infection  after  abortioji  is  similar  to  that  after  labor. 
But  the  smaller  uterus  with  its  less  active  lymphatics  and 
vessels,  when  infected,  produces  less  septicaemia.  The 
gravity  of  the  symptoms  is  Usually  in  direct  ratio  to  the 
period  of  gestation.  The  infections  after  early  abor- 
tions, as  at  the  fourth  week,  take  on  the  type  of  endo- 
metritis. The  later  abortions  assume  the  characteristics 
of  infection  at  full  term.  The  line  cannot  be  sharply 
drawn  between  those  cases  to  be  classed  purely  as  abor- 
tions and  those  which  shall  be  called  puerperal. 

It  is  eminently  proper  that  I  describe  in  a  separate 
chapter  the  forms  of  infection  occurring  during  the  puer- 
perium.  More  especially  am  I  prompted  to  do  this  be- 
cause the  method  of  treatment  I  employ  is  somewhat 
different  from  that  of  most  sureeons  and  because  these 


ENDOMETRITIS. 


35 


cases  commonly  fall  into  the  hands  of  the  general  prac- 
titioner. 

The  puerperal  uterus  may  be  the  seat  of  an  invasion  by 
any  one  of  the  pyogenic  cocci  and  various  bacilli.  The 
lesser  degrees  of  infection  are  caused  by  staphylococci 
and  the  more  virulent  by  streptococci.  These  produce 
septic  endometritis.  Certain  saprophytes  when  intro- 
duced into  the  puerperal  uterus  produce /?//77'ir/  endome- 
tritis. 

The  activity  of  these  microbes  results  in  the  produc- 
tion of  toxins  which  alter  the  chemical  processes  in  the 
body  and  may  cause  death. 

The  infection  starts  in  the  endometrium  and  may  be 
general  over  the  whole  inside  of  the  organ  or  limited  to 
the  placental  site. 

If  putrid  infection  occurs  there  will  be  found  over  a 
certain  area  of  the  endometrium  a  patch  of  slough  in 
which  the  saprophytes  are  situated,  more  or  less  mixed 
with  other  germs.  Beneath  this  patch  there  is  arranged 
in  the  endometrium  an  aggregation  of  white  blood  cor- 
puscles whose  presence  tends  to  prevent  an  extension  of 
the  saprophytes  into  the  deeper  parts  of  the  organ. 

In  septic  infection  the  cocci  lie  either  upon  the  surface 
of  the  endometrium,  within  it,  or  may  even  penetrate  into 
the  peri  uterine  structures. 

Putrid  infection  results  in  a  sapraemia,  while  septic 
infection  causes  a  septicaemia. 

Putrid  infection,  pure  and  unmixed  with  septic  germs, 
is  a  superficial  affection  and  does  not  destroy  life.  But 
inasmuch  as  the  necrotic  area  is  so  likely  to  become  the 
point  of  entry  of  septic  germs,  the  appearance  of  sap- 
rsemia  is  often  the  forerunner  of  a  septic  process. 

Septic  Puerperal  Endometritis.- — The  cocci  enter  the 
walls  of  the  uterus  through  the  lymphatics  or  the  vein's. 
As  they  proceed  we  have  perhaps  the  veins  filled  with 
infected  blood  clots,  tlirombo-pldebitis;  or  there  may  be  a 
pelvic,  then  a  general,  lymphangitis  (Fig.  lo).  The  perito- 
neum lying  near  the  infected  spots  throws  out  a  quantity 
of  serum  and  lymph  and  a  peritonitis  results.  Immediately 


PELVIC    INFLAMMATION. 


Fig.  io. — Lymphatics  of  the  pelvic  visccra^and^abdomen  :  A,  Aorta;  B,  15, 
iliac  arteries;  C,  C,  the  bifurcation  and  two  branches  of  the  iliac  arteries;  D, 
vena  cava;  E,  left  renal  vein;  F,  right  renal  vein;  G,  iliac  veins;  H,  H,  ure- 
ters, I,  rectum;  K,  uterus;  L,  cervix;  M,  M,  vaginal  walls;  N,  N,  Fallopian 
tubes  ;  P,  P,  ovaries  ;  Q,  Q,  round  ligaments  ;  i,  Deep  lymphatic  vessels  of  the 
right  kidney,  and  ganglia  into  which  they  empty;  2,  2,  2,  2,  superficial  lym- 
phatic vessels;  3,  3.  3,  3,  the  same ;  4,  two  gangha  that  receive  these  superfi- 
cial vessels;  7,  7,  subovarian  plexus  of  lymphatics;  8,  8,  ducts  leading  from 
this  plexus;  9,  g,  the  same;  10,  10,  11,  11,  glands  receiving  these  ducts;  12, 
12,  12,  12,  lymphatic  ducts,  originating  m  the  fundus  uteri,  and  terminating  in 
the  same  glands  as  the  ovarian  ducts  ;  13,  13,  ducts  from  the  anterior  surface 
and  sides  of  the  uterus;  14,  14,  glands  into  which  they  empty;  15,  15,  ducts 
originating  in  cervix  and  upper  part  of  vagina ;  16,  16,  glands  into  which  they 
e.npty;  17,  17,  efferent  vessels  of  these  glands;  18,  18,  lymphatic  ducts  from 
posterior  surface  of  the  uterus  and  glands  into  which  they  empty  ;  19,  lumbar 
gland  (exceptional);  20,  gland  into  which  occasionally  a  duct  from  lower  uter- 
ine segment  empties  (Sappey). 


ENDOMETRITIS. 


37 


adjacent  to  the  infected  vessels  suppuration  may  occur, 
and  this  may  take  place  primarily  in  the  folds  of  the 
broad  ligament  or  in  the  ovary,  and  subsequently  the 
fallopian  tube  and  pelvic  peritoneum  may  be  the  seat  ot 
a  suppurative  process  (Fig.  ii). 

In  some  cases  the  gross  lesions  are  all  local,  but  occa- 
sionally as  in  cases  reported  by  the  author  as  early  as 
1886,  and  again  in  1895,  spe- 
cimens have  been  shown  in 
fatal  cases  where  there  were 
no  gross  lesions  observable  in 
the  pelvis,  but  only  at  some 
distant  point,  such  as  the  dia- 
phragmatic peritoneum,  the 
pleura  or  the  heart  membranes. 

The  more  virulent  and  rapid 
the  infection  the  less  are  the 
local  manifestations  of  the  dis- 
which     die. 


ease     m 


Fig.  II. —  Streptococcus  pyogenes 

in  pus  (X  1000)  (Frankel  and 

Pfeiffer). 


cases 
There  is  in  some  instances 
produced  a  stasis  in  the  in- 
fected uterus,  and  before  it  is  possible  for  masses  of 
lymph  to  be  effused  or  pus  to  be  produced  the  patient  is 
dead.  A  fatal  result  of  course  more  speedily  ensues  in 
the  thrombo-phlebitic  type.  If  the  patient  recovers 
through  the  action  ofnatural  processes  only,  it  will  be  with 
damaged  pelvic  organs.  The  pelvic  lymphangitis  results 
in  the  production  of  connective  tissue  in  the  broad  liga- 
ments, which  bind  and  fix  the  uterus.  The  effusion  of 
lymph  upon  the  pelvic  peritoneum  results  in  the  occlu- 
sion of  the  tubes  and  all  the  various  forms  of  adhesions 
to  be  found  in  the  pelvis.  There  may  also  be  found  pus 
foci  in  the  broad  ligament,  the  ovary,  or  even,  as  a 
secondary  complication,  in  the  tube.  The  organs  higher 
in  the  abdomen  may  be  bound  to  each  other,  and  there 
may  be  adhesions  in  the  diaphragmatic  pleura.  As  a 
result  of  endocarditis  the  valves  become  distorted  and 
permanent  heart  lesions  are  found.  Throughout  the 
body,    along    the    lymphatics    of    the    supra-clavicular 


^S  PELVIC   INFLAMMATION. 

spaces,  in  those  of  the  groins  and  at  other  points  buboes 
may  form  and  result  in  disfiguring  scars.  A  thrombo- 
phlebitis in  a  leg  may  permanently  interfere  with  its  cir- 
culation, and  articular  inflammations  result  in  stiff  joints. 
Finally,  any  one  or  all  of  the  results  of  a  profound 
degree  of  general  septiccEmia  may  be  noted.  The 
graver  sequelae  are  endocarditis,  pneumonitis  and  nephri- 
tis. Naturally  women  who  have  suffered  from  septicae- 
mia are  particularly  prone  to  contract  phthisis. 

It  is  not  the  province  of  this  book  to  enter  more 
elaborately  into  a  description  of  the  methods  of  con- 
tagion, etc.,  for  these  points  are  elaborated  in  many  works 
on  obstetrics.  I  have  stated  enough  to  show  the  im- 
portance of  early  treatment,  not  only  that  life  may  be 
saved — we  have  passed  beyond  that — but  that  the  rav- 
ages of  sepsis  in  the  system  may  be  prevented.  We 
have  ceased  to  be  guided  solely  by  the  mortality,  and 
are  attacking  the  morbidity  statistics  (Fig.  12). 

Post  partum  women  may  have  a  rise  in  temperature 
from  general  causes  as  well  as  from  intra-uterine  infec- 
tion. Before  proceeding  to  treat  the  uterus,  the  respon- 
sibility for  the  rise  in  temperature  must  be  placed  there. 
It  is  taken  for  granted  that  so  soon  as  the  pyrexia  has 
been  noticed,  the  attending  physician  has  eliminated  the 
element  of  intestinal  toxicosis  by  washing  out  the  colon 
with  normal  salt  solution,  and  likewise  has  proven  the 
case  non-malarial  by  the  administration  of  a  large  dose 
of  quinin.  It  is  an  undoubted  fact  that  seventy-five  out 
of  every  hundred  women  who  have  a  rise  in  temperature 
after  labor,  will  reach  a  normal  state  in  a  few  days,  if  left 
alone.  But  among  the  other  twenty- five  will  be  found  a 
few  who  will  perish  in  a  few  days  if  not  treated,  and  the 
others  of  that  number  will  be  invalids  for  life.  It  is 
most  desirable  that  every  physician  in  America  have  the 
ability  to  make  cultures  from  the  inside  of  the  uterus, 
and  in  this  way  be  able  to  differentiate  the  various 
causes  of  puerperal  fever.  Still,  few  of  the  expert 
bacteriologists  agree  upon  one  plan  of  collecting  these 
discharges,  and  they  are  still   debating  about   it.     The 


Fig.  12. — Specimen  from  a  patient  who  died  septic,  showing  the  material 
that  would  be  found  to  be  removed  by  the  curette  or  the  finger  on  the 
"  roughened  placental  site."  "  Clots  in  the  uterine  sinuses"  (Army  Medical 
Museum,  Washington,  D.  C,  No.  10,619).  ("An  American  Text-Book  ol 
Obstetrics.") 


ENDOMETRITIS. 


4T 


fact  remains,  anyway,  that  the  great  body  of  the  profes- 
sion prefers  to  be  governed  by  clinical  symptoms  rather 
than  bacteriological  examinations  when  made  by  any 
except  the  most  skilled.  Therefore,  the  family  physi- 
cian who  attends  most  of  these  cases  of  puerperal  fever 
must  either  waste  important  time  while  determining  that 
a  given  case  is  virulent  streptococcus  infection  or  not,  or 
else  he  must  apply  that  method  of  treatment  which  will 
do  good  in  all  cases  and  harm  in  none:  At  least;  any 
sensible  man  will,  though  a  theorist  may  not. 

Having  flushed' out  the  bowel,  cinchonized  the  patient 
and  having  excluded  all  other  causes  for  the  fever,  if  the 
patient  evidently  suffers  from  an  infection  starting  from 
the  uterus,  I  proceed  as  follows  : 

Treatment. — The  patient's  vagina  should  be  thor- 
oughly cleansed  by  a  prolonged  douching  with  bichloride 
of  mercury  solution,  i  :  io,000.  The  operator  prepares 
his  hands  and  material  as  described  in  the  article  upon 
sterilization.  All  of  this  is  done  before  an  examination 
is  made.  Inasmuch  as  putrid  infection  remains  superfi- 
cial and  sepsis  at  one  stage  is  also  only  upon  the  surface 
of  the  endometrium,  I  advocate  intra-uterine  douches. 
The  time  element  is  important.  If  seen  within  twelve 
hours  of  the  onset  of  the  first  evidences  of  infection, 
before  the  germs  have  penetrated  the  deeper  layers  of 
the  decidua,  intra-uterine  irrigations  will  cure.  But  if 
the  patient  is  seen  after  the  germs  have  passed  into  the 
decidua,  some  antiseptic  must  be  employed  which  will 
be  more  rapidly  absorbed  than  they  can  proceed,  as 
iodin  in  the  form  of  iodoform.  If  they  have  passed  still 
deeper,  curettage  is  needed. 

Should  the  invasion  have  passed  outside  the  uterus, 
curettage  and  the  cul-de-sac  incision  with  proper  dress- 
ings applied  to  the  pelvis  will  cure  nearly  every  case. 
The  excepted  cases  are  those  in  which  purulent  perito- 
nitis has  set  in,  cases  of  thrombo-phlebitis,  and  those 
with  some  mortal  complication,  as  endocarditis.  Rarely 
will  hysterectomy  be  indicated,  so  rarely  in  fact  that  I  ad- 
vise against  it  except  under  the  circumstances  which 
surround  one  in  a  perfectly  appointed  hospital. 


42 


PELVIC   INFLAMMATION. 


Puerperal  infection  is  wound  infection  and  should  be 
treated  as  such. 

Irrigation  of  the  Uterus. — The  vulva  should  be 
shaved  and  the  patient  placed  in  the  lithotomy  posture 
on  the  table,  with  a  suitable  arrangement  made  for 
catching  the  irrigating  fluids.  A  sheet  tightly  rolled 
and  shaped  like  a  horseshoe  may  be  laid  under  the 
buttocks,  and  a  piece  of  rubber  cloth  over  this  will  pro- 
tect the  clothing  and  floor.  The  vagina  is  irrigated 
with  four  quarts  of  bichloride  solution  i  :  10,000.  The 
perineum  is  drawn  down  by  either  a  speculum  or  the 
fingers  and  the  anterior  lip  of  the  cervix  is  seized  with 
my  blunt  bullet  forceps  (see  Fig.  42)  and  drawn  down. 
The  largest  return-flow  irrigating  tube  (see  No.  4,  Fig. 
49)  is  then  passed  to  the  fundus.  In  doing  this  the  in- 
strument is  not  allowed  to  touch  any  part  of  the  patient 
until  the  cervix  is  reached,  and  the  utmost  gentleness  is 
employed  to  avoid  bruising  the  endometrium.  The 
tube  of  the  fountain  syringe  is  then  attached  and  the 
current  turned  on.  I  first  allow  one  quart  of  Thiersch 
solution  to  pass  into  the  uterus,  to  be  followed  by  six  or 
eight  quarts  of  boric  acid  or  salt  solution  (see  Fig.  9). 

Frequently  this  one  washing  will  suffice  to  control  all 
symptoms.  The  operator  remains  in  the  house  for  an 
hour  and  repeats  the  procedure.  The  rectal  temperature 
is  taken  every  half  hour.  If  in  four  hours  the  tempera- 
ture is  not  normal,  the  uterus  is  again  irrigated,  and  is 
packed  full  of  iodoform  gauze,  10  per  cent,  strength. 
This  packing  is  made  in  the  following  manner:  The 
strips  of  gauze  are  four  inches  wide.  While  steadying 
the  uterus  with  the  heavy  forceps,  the  operator  seizes 
the  end  of  the  gauze  in  Hunter's  forceps,  and  passes  it 
to  the  fundus.  He  continues  to  insert  the  strip  until  the 
uterus  is  filled,  the  end  of  the  gauze  extending  into  the 
vagina.  The  vagina  is  then  packed  with  iodoform 
gauze.  The  iodoform  becomes  rapidly  disintegrated  in 
the  presence  of  the  uterine  discharges  and  free  iodin  is 
detected  in  the  urine  in  three  hours. 

If  in  twenty-four  hours  after  this,  the  temperature  is 


ENDOMETRITIS. 


43 


not  normal,  the  operator  proceeds  to  curette  the  uterus 
and  open  the  cul-de-sac;  for  the  infection  being  no 
longer  superficial,  it  is  impossible  to  say  how  far  it  has 
extended;  presumably  it  has  passed  to  the  peri-uterine 
lymphatics,  and  it  will  be  necessary  to  treat  these  by 
sterilizing  dressings. 

But  if  the  temperature  is  normal  in  a  day,  the  packing 
is  allowed  to  remain  in  the  uterus  for  forty-eight  hours 
and  is  then  withdrawn.  It  is  not  renewed.  It  is  almost 
needless  to  say  that  the  presence  of  retained  membranes 
or  placenta  requires  their  careful  renewal  before  institut- 
ing this  treatment.  I  must  advise  against  digital  explora- 
tion of  the  uterine  cavity,  unless  it  is  followed  by  irriga- 
tion and  gauze  packing.  It  is  most  difficult  to  disinfect 
the  finger,  whereas  instruments  are  easily  cleansed  by 
boiling.  Whenever  I  suspect  the  presence  of  placental 
tufts  or  membranes  their  removal  is  to  be  made  under 
chloroform  by  Luer's  forceps  or  Munde's  curette. 

And  if  retained  placenta  is  accompanied  by  symptoms 
of  sepsis,  its  removal  is  to  be  accompanied  by  curettage 
of  the  uterus;  for  it  is  presumed  that  under  the  circum- 
stances the  infection  also  invades  portions  of  the  endome- 
trium other  than  the  placental  site. 

Curettage. — The  uterus  is  drawn  down  as  before  and 
washed  out  with  several  quarts  of  bichloride  i  :  1 0,000. 
The  antiseptic  is  not  contraindicated  here,  for  it  is  in- 
tended to  remove  the  decidua  and  no  slough  will  follow 
its  use.  Taking  the  largest  sized  curette,  the  operator 
introduces  it  into  the  uterus  and  systematically  curettes 
the  entire  surface.  It  will  not  be  necessary  to  use  force 
as  the  tissue  is  soft.  The  bleeding  is  pretty  free,  but  is 
to  be  ignored.  After  curetting  the  organ,  it  is  again 
washed  out  with  the  large  irrigator,  which  has  been 
resterilized  while  the  curettage  was  proceeding.  At  this 
second  washing  I  employ  boiled  salt  solution  at  a  temper- 
ature of  about  115°  F.  The  uterus  is  then  packed  full 
of  iodoform  gauze,  10  per  cent,  strength.  The  size  of 
the  cervical  canal  will  largely  govern  the  width  of 
the  strip  to  be  used.     As  the  patient  is  under  chloro- 


44 


PELVIC   INFLAMMATION. 


form  a  large  strip  can  be  inserted,  usually  nine  inches 
in  width.  The  organ  is  to  be  tightly  packed,  and  the 
vagina  also  filled.  In  two  days  these  dressings  are  re- 
moved, and  a  second  packing  made,  but  not  so  firmly. 
The  cervix  will  be  found  widely  open.  This  second 
dressing  is  taken  out  in  two  days  more  and  the  patient 
is  put  on  ergot  and  quinia. 

If  this  treatment  has  not  subdued  the  symptoms  in 
forty-eight  hours,  the  cul-de-sac  must  be  opened. 

The  Cul-de-Sac  Operation. — Whenever  I  curette  the 
uterus  for  se/^si's  I  immediately  open  the  cul-de-sac.  In 
cases  of  putrid  infection  and  where  retained  placenta  is 
sought  curetting  alone  will  suffice.  But  in  the  presence 
of  sepsis  which  has  not  yielded  to  the  non-operative  pro- 
cedures, I  have  never  been  able  to  determine  how  deeply 
in  the  tissues  the  infection  has  extended.  And  as  the 
cul-de-sac  operation  is  devoid  of  danger,  and  my  anx- 
iety is  great  lest  the  infection  run  away  from  my  reach, 
I  always  open  the  cul-de-sac  whenever  I  curette  for 
sepsis,  z.  e.,  when  milder  procedures  have  failed. 

The  patient  is  under  chloroform.  The  vagina  is  pre- 
pared as  described  elsewhere ;  and  if  there  could  be 
degrees  in  cleanliness  I  would  urge  the  highest  here. 

After  curetting  the  uterus  it  is  packed  with  gauze. 
Selecting  the  fold  just  behind  the  cervix,  it  is  picked  up 
with  forceps  and  cut  through  for  a  space  of  a  half-inch. 
The  cut  extends  through  the  mucous  meriibrane  only. 
The  finger  is  then  shoved  into  the  pelvis.  About  two 
minutes  are  consumed  in  this.  Upon  withdrawing  the 
finger  quite  a  quantity  of  serum  escapes.  The  operator 
carefully  notices  the  character  of  the  fluid  which  escapes. 
He  passes  his  finger  back  and  forward  behind  the  broad 
ligament  and  gently  palpates  the  adnexa.  If  the  organs 
are  found  matted  together  by  lymph,  they  are  liberated 
with  the  finger.  I  seek  to  make  this  digital  exploration 
and  separation  of  adhesions  of  the  broadest  kind,  my 
object  being  to  open  the  lymph  spaces  not  only  that 
they  may  discharge  into  the  dressing  which  I  am  about 
to  apply,  but  that  the  antiseptic  may  be  readily  absorbed. 


ENDOMETRITIS.  45 

Wherever  there  is  an  effusion  of  lymph  there  is  a  con- 
test between  germs  and  the  tissues.  Into  this  combat  I 
wish  to  enter. 

Having-  examined  the  pelvis  and  separated  all  adherent 
organs,  I  insert  two  fingers  into  the  cul-de-sac  and  stretch 
the  opening  to  a  level  with  the  sides  of  the  cervix.  The 
pelvis  is  then  filled  with  strips  of  iodoform  gauze  (see 
Fig.  38).  These  pieces  are  made  by  taking  a  strip  of 
gauze  a  yard  long  and  four  inches  wide,  and  folding  it 
until  the  shape  represented.  The  strips  extend  up  to 
the  level  of  the  fallopian  tubes.  They  are  inserted  as 
described  in  the  article  on  hysterectomy.  The  vagina 
is  packed.  If  the  patient's  pulse  runs  under  the  ether  to 
140,  I  deem  it  the  indication  of  a  profound  degree  of 
septicaemia.  It  is  then  my  duty  to  increase  the  action 
of  the  kidneys  as  well  as  stimulate  the  heart.  I  there- 
fore introduce  into  a  vein  from  one  to  two  quarts  of  salt 
solution  (see  salt  solution).  This  I  also  do  whenever  I 
find  that  the  lymph  in  the  pelvis  is  breaking  down  into 
pus,  and  whenever  there  are  grave  complications  as  pneu- 
monia and  nephritis.  It  is  a  question  in  my  mind 
whether  it  be  not  advisable  to  employ  this  in  all  cases 
of  streptococcus  infection  and  at  present  such  is  my 
practice,  but  I  am  not  prepared  to  advise  its  general  use. 

Within  a  day  after  this  operation  the  bed  will  be  found 
soaked  with  the  muddy,  toxin-laden  serum  from  the 
pelvis.  The  amount  must  be  pints  in  quantity  in  some 
cases,  and  the  patient  will  feel  the  loss  of  so  much  fluid 
unless  provision  be  made  to  supply  it.  I  therefore  in- 
ject into  the  bowel  eight  ounces  of  tepid  salt  solution 
every  three  hours  for  several  days.  The  patient  is  stimu- 
lated by  hypodermics  of  strychnia,  but  I  do  not  believe- 
in  excessive  doses.  I  usually  give  gr.  i  :  50,  q.  4.  h.  A 
few  hours  after  the  operation  I  begin  giving  fluids  by 
the  mouth.  If  stimulants  are  needed  I  give  either  an 
ounce  of  champagne  every  hour  or  a  teaspoonful  of 
brandy  in  an  ounce  of  water.  If  alcoholics  are  not  neces- 
sary, I  give  hourly  an  ounce  of  cold  water  to  which  has 
been   added  five  drops   of  lemon  juice.     The   urine   is 


46 


PELVIC   INFLAMMATION. 


drawn- every  three  hours  and  is  measured.  It  is  tested 
for  albumen  and  iodin.  I  begin  to  adminster  hquid  food 
after  eighteen  hours,  beginning  with  a  little  hot  chicken- 
broth  or  squeezed  juice  of  broiled  steak.  In  three  days 
I  remove  the  vaginal  packing  and  the  uterine  gauze. 
The  vaginal  packing  is  renewed,  but  the  uterine  is  not 
unless  the  septic  symptoms  persist.  The  cul-de-sac 
dressing  is  taken  out  in  a  week  and  is  replaced  by  fresh 
gauze  of  5  per  cent,  strength. 

These  dressing  are  repeated  every  four  to  seven  days 
until  the  opening  closes.  After  that  I  apply  ichthyol 
tampons  to  promote  involution.  In  conjunction  with  Dr. 
Jeffries,  bacteriologist  to  the  Polyclinic,  I  have  instituted 
a  series  of  experiments  in  the  influence  of  these  dressings 
upon  the  streptococci  usually  found  in  these  cases.  I 
have  in  fifteen  cases  placed  the  uterine  scrapings  in  a 
sterile  tube  and  the  fluid  from  the  cul-de  sac  m  another. 
Whenever  streptococci  have  been  found,  even  though 
pus  was  free  in  the  peritoneal  cavity  in  one  case,  and 
sacculated  in  several  others,  we  have  never  failed  to  find 
that  the  dressings  absolutely  sterilized  the  operation  field. 
This  is  usually  accomplished  by  the  third  dressing,  but 
in  one  case  not  before  the  fifth  had  been  used.  And  in 
many  cases  where  no  bacteriologic  examinations  were 
made  the  treatment  was  equally  successful. 

So  far  as  results  are  concerned,  I  have  not  lost  a  pa- 
tient so  treated.  The  success  of  this  operation  in  a  class 
of  cases  formerly  thought  worthy  of  hysterectomy  con- 
vinces me  that  the  latter  operation  is  unnecessary.  And 
inasmuch  as  the  operation  is  exceedingly  simple  and 
requires  no  elaborate  equipment  of  nurses,  assistants, 
and  material,  I  shall  expect  it  to  become  of  general  adop- 
tion by  those  who  have  the  surgical  conception  of  the 
treatment  of  this  dreadful  disease. 

The  importance  of  the  proper  treatment  of  this  form 
of  infection  is  well  shown  by  the  report  of  the  Registrar 
General  for  England  and  Wales  for  the  year  1895.  Out 
of  every  thousand  deliveries  two  women  died  from  some 
form  of  infection.  The  morbidity  in  those  that  recovered 
must  have  been  appalling. 


ENDOMETRITIS.  47 


ACUTE  GONORRHEAL  ENDOMETRITIS. 

The  sole  caustive  germ  is  the  gonococcus,  but  the 
infection  is  often  a  mixed  one,  other  cocci  besides  the 
gonococcus  being  present.  Occasionally  a  woman  will 
have  gonorrheal  vulvitis,  vaginitis,  or  endocervicitis  for 
some  time  without  an  extension  to  the  endometrium ; 
but  prolonged  exposure,  menstruation,  overindulgence  in 
coition,  and  any  operation  upon  the  uterus,  or  even  the 
passage  of  the  sound,  will  cause  a  sudden  attack  of  gon- 
orrheal endometritis. 

Symptoms. — These  cannot  be  better  brought  out  than 
by  describing  a  case.  A  girl  of  twenty-two  married  two 
weeks  before  an  expected  period,  a  man  with  gleet. 
Five  days  afterward  she  began  to  have  painful  and  fre- 
quent urination,  and  in  a  few  days  more  a  vulvovaginal 
swelling  appeared  upon  the  right  side.  She  thought 
these  symptoms  due  to  frequent  connections,  and  bore 
her  distress  with  good  grace.  There  was  a  profuse  puru- 
lent discharge  from  the  vulva,  and  she  was  compelled  to 
bathe  frequently.  The  menstruation  appeared  on  time, 
and  was  normal  up  to  the  third  day.  She  then  had  sharp, 
lancinating  pains  in  the  uterus  accompanied  by  the  most 
severe  cramps.  The  menstrual  flow  increased  in  amount, 
and  three  days  after  the  onset  of  the  severe  symptoms 
she  had  a  most  irritating  and  profuse  yellow  discharge. 
She  took  to  bed.  The  entire  pelvis  became  so  tender 
that  she  could  not  bear  to  be  touched.  The  pus  was 
mixed  with  blood.  The  rectal  temperature  when  I  saw 
her  on  the  tenth  day  was  lOi.8°  F.,  and  the  pulse  was 
106.  Upon  examination,  I  found  a  vulvovaginal  abscess 
discharging.  The  uterus  was  exquisitely  sensitive,  and 
the  uterine  spasms  continued  after  the  menstrual  flow 
ceased.  The  cervix  was  livid  in  hue,  sind  markedly 
eroded.  It  seemed  to  be  entirely  devoid  of  epithelial 
covering,  and  from  the  os  hung  a  rope  of  tenacious  yel- 
low discharge.    The  microscope  showed  the  gonococcus. 

Such  is  a  picture  of  an  average  case.     The  uterine 


48 


PELVIC    INFLAMMATION. 


infection  may  take  place  at  any  time,  but  it  is  most  apt 
to  occur  during  menstruation,  when  the  uterine  epithe- 
lium is  exfoliated.  Several  days  elapse,  as  a  rule,  between 
the  onset  and  the  appearance  of  pus.  The  pus  is  produced 
in  great  quantities,  as  much  as  several  ounces  in  twenty- 
four  hours.  It  is  tinged  with  blood  in  nearly  all  cases, 
so  deep  is  the  congestion.  The  body  temperature  is  ele- 
vated^ but  rarely  goes  to  103°  F.  The  pulse  is  accelerated 
up  to  1 10  in  the  worst  cases.  The  symptoms  subside 
slowly,  but  the  purulent  discharge  continues  for  some 
time,  and,  as  a  rule,  the  case  becomes  chronic.  Rarely 
does  a  cure  occur  without  treatment,  and  complications 
are  very  common.  The  uterus  in  the  acute  stage  is  en- 
larged ;  but  after  repeated  attacks  it  may  become  little 
more  than  a  mass  of  fibrous  tissue,  being  hard  and  small. 
Such  uteri  we  find  in  old  prostitutes.  Women  with  acute 
gonorrheal  endometritis  take  to  bed.  The  suffering  is 
continuous,  and  the  pain  is  marked  by  sharp  exacerba- 
tions— "  uterine  colic."  The  course  of  an  attack  persists 
through  one  or  two  weeks  and  results  in  either  a  chronic 
condition  or  some  grave  coriiplication. 

Diag-nosis. — There  will  usually  be  found  other  evi- 
dences of  gonorrhea,  such  as  urethritis  or  vulvitis.  A 
woman  previously  well  suddenly  attacked  with  acute 
endometritis  a  few  days  after  connection  probably  has 
gonorrhea.  By  far  the  greater  number  of  such  cases 
of  acute  endometritis  which  do  not  occur  after  abortion 
or  labor  are  due  to  gonorrhea.  Indeed,  I  am  warranted 
in  saying  that  gonorrhea  is  a  disease  of  the  non-pregnant 
uterus,  while  sepsis  is  most  frequently  found  to  follow 
conception. 

The  temperature,  the  great  pain  in  the  uterus,  the 
profuse  purulent  discharge,  the  excoriations  produced 
in  the  cervix  and  vagina  by  the  pus,  the  presence  of 
other  evidences  of  clap  will  render  the  diagnosis  clear. 
In  all  cases  the  gonococcus  is  found. 

Treatment — ]Sr<ni -Operative. — The  vulva  and  vagina, 
if  infected,  should  be  painted  with  silver  nitrate  solution, 
gr.  XX  to  oz.  j.     With   a  sharp  bistoury  the   cervix  is 


ENDOMETRITIS. 


49 


bled.  If  the  cervix  is  open  enough  the  uterus  should 
be  washed  out  with  either  bichlorid  solution,  i  :  lo,ooo, 
or  else  with  a  saturated  solution  of  boric  acid.  (See 
Septic  Endometritis.)  I  prefer  to  use  both  solutions  at 
the  same  sitting,  the  latter  following  the  other.  This 
treatment  I  repeat  in  twelve  or  twenty-four  hours.  In 
the  interim  I  order  douches  of  %  per  cent,  lysol  at  a 
temperature  of  iio°F.  every  two  hours.  If  the  case  is 
seen  early  such  treatment  will  often  result  in  subduing 
acute  symptoms  after  four  days.  But  if  the  patient  is 
not  seen  before  the  cocci  have  penetrated  into  the  deeper 
portions  of  the  endometrium,  or  if  the  cervix  be  markedly 
stenosed,  the  uterine  washings  are  useless  or  can  not  be 
applied.  The  local  blood-letting  should  be  employed 
but  once  or  twice,  and  the  co-existing  vulvitis  and  vag- 
initis will  not  require  applications  of  silver  solutions 
more  than  once  a  day.  It  is  wise  to  pack  the  vagina 
with  iodoform  gauze  wet  in  bichlorid,  1:4,000.  This 
dressing  not  only  supports  the  uterus  against  painful 
jarring,  but  it  also  sterilizes  the  vagina  as  well  as  the 
discharge  from  the  uterus.  But  it  is  not  to  be  used  in 
cases  where  intra-uterine  washings  are  impossible,  for 
there  it  will  but  dam  up  the  discharges.  Opiates  will 
usually  be  found  necessary  for  the  relief  of  pain. 

Operative  Treatment. — Whether  seen  early  or  late 
after  infection,  I  prefer  to  curette  these  cases.  (See 
Curettage.)  Certain  teachers  consider  complications 
almost  sure  to  result  from  such  treatment,  but  the  reason 
for  these  ill  results  will  be  found  in  the  method  of  oper- 
ating. I  can  see  no  reason  for  discriminating  in  favor 
of  the  gonococcus  as  against  other  pyogenic  cocci.  Cer- 
tainly the  worst  that  can  result  from  operating  is  a  com- 
plication, and  this  follows  the  let-alone  treatment  in 
nearly  all  instances.  Indeed,  it  is  doubtful  if  a  general 
gonorrheal  endometritis  ever  runs  its  course  without 
producing  some  inflammatory  process  in  either  the  tubes, 
ovaries,  or  pelvic  peritoneum. 

Sequelae.  —  Gonorrhea    of    the    uterus     extends     not 
through  the  lymph  streams,  but   through  the  tubes — 
4 


so 


PELVIC   INFLAMMATION, 


extension  by  continuity  of  tissue.  As  a  result  we  have 
salpingitis,  ovaritis,  and  peritonitis  the  complications, 
and  never  see  primary  broad  ligament  abscess  result. 
In  view  of  the  ravages  which  unchecked  gonorrhea 
works  in  a  woman's  pelvis,  the  very  first  symptom  must 
be  vigorously  met.  The  joint  complications  sometimes 
seen  in  men,  I  have  never  seen  in  women,  but  they  do 
occasionally  occur.  Women  who  have  had  true  gonor- 
rheal endometritis  and  in  whom  it  is  not  radically  cured 
are  always  sterile.  Those  cases  which  do  not  produce 
some  complication  result  in  a  chronic  condition.  My 
belief  is  that  gonorrhea  of  the  endometrium  is  never  cured 
except  by  surgical  means. 

CHRONIC  GONORRHEAL  ENDOMETRITIS. 

Symptoms. — Chronic  gonorrheal  endometritis  is  about 
the  happiest  result  to  be  expected  from  an  acute  attack. 
I  do  not  find  the  chronic  state  other  than  as  a  result  of 
the  acute.  There  is  slight  enlargement  of  the  uterus  in 
some  cases ;  but  old  cases  who  have  had  repeated  attacks, 
have  usually  small,  hard  uteri.  The  cervix  in  all  is 
usually  the  seat  of  folliculitis  with  erosions.  There  is 
always  a  purulent  discharge.  The  condition  may  exist 
without  pelvic  complications,  but  I  have  neve}'  seen  jt. 
Uterine  pain  is  not  present,  but  where  the  uterus  is  per- 
sistently enlarged  there  is  a  sense  of  weight  in  the  pelvis. 
Whenever  in  such  cases  there  is  marked  pelvic  pain,  it 
is  an  absolute  indication  that  the  causative  acute  attack 
has  resulted  in  damage  to  the  periuterine  tissues.  As  a 
result  of  the  aggressiveness  of  pelvic  surgery  a  good 
many  supposed  conditions  have  been  properly  eliminated 
from  our  pathology,  and  many  apparently  innocent  states 
of  the  uterus  have  been  found  to  be  accompanied  by  pro- 
nounced disease  in  the  adnexa.  As  I  said  above,  I  do  not 
find  chronic  corporal  gonorrheal  endometritis  without 
complications.  It  is  these  complications  so  difficult  to 
detect  which  produce  the  distressing  symptoms  and  not 
the  chronic  inflammation  in  the  uterus.  These  women 
are  generally  sterile. 


ENDOMETRITIS. 


51 


Diagnosis. — For  clinical  purposes  chronic  inflamma- 
tions of  the  uterus  are  characterized  by  one  prominent 
symptom — a  purulent  discharge.  There  being  no  evi- 
dence of  adnexal  disease,  we  may  put  the  case  down  as 
not  due  to  gonorrhea.  But  far  more  difficult  is  it  to 
determine  whether  the  cervix  alone  or  the  entire  endo- 
metrium is  involved.  To  settle  this  the  endocervicitis 
must  first  be  cured.  If  this  is  easily  accomplished,  the 
flow  of  pus  checked,  and  relapses  without  apparent  cause 
do  not  occur,  we  can  be  sure  that  the  pus  did  not  come 
from  above  the  os  internum.  But  where  the  cervix  re- 
mains inflamed  under  persistent  treatment,  or  where  the 
purulent  discharge  continues  after  the  cervix  is  brought 
to  a  normal  condition,  we  may  know  that  the  endome- 
trium is  involved.  The  persistence  of  the  discharge 
despite  energetic  measures  applied  to  the  cervix  con- 
vinces us  that  the  corporal  endometrium  is  inflamed. 
The  patient's  word  cannot  be  relied  upon  in  determining 
this,  for  she  probably  douches  and  washes  away  dis- 
charges. A  piece  of  cotton  large  enough  to  fill  the 
vaginal  vault  is  wrung  out  in  Thiersch  solution  and  ap- 
plied over  the  cervix.  It  is  kept  there  by  vaginal  tam- 
pons. In  twelve  hours  it  is  removed  and  the  amount  of 
pus  discharged  in  that  time  can  be  determined. 

Treatment. — The  presence  of  adnexal  disease  is  no 
bar  to  the  methods  of  treatment.  If  the  cervix  be  suffi- 
ciently open  for  the,  purpose,  the  uterus  may  be  washed 
out  (see  Septic  Endometritis).  But  as  all  the  cases  of 
chronic  general  gonorrheal  endometritis  which  I  have 
met  have  some  degree  of  adnexal  disease,  I  advocate 
curettage  and  the  cul-de-sac  operation  (see  Cul-de-Sac 
Operation).  A  curettage  alone  undoubtedly  checks  the 
source  of  infection,  and,  following  it,  some  repair  ensues 
in  the  inflamed  adnexa.  But  we  must  consider  both  in- 
tra-uterine  washings  and  curettage  as  merely  palliative. 
If  a  radical  cure  is  to  be  effected,  the  adnexa  must  be 
directly  treated  through  the  cul-de-sac.  For  a  long  time 
it  has  been  my  behef  that  chronic  gonorrheal  endome- 
tritis is  never  found  except' as  a  result  of  an  acute  pro- 


5  2  PELVIC   INFLAMMATION. 

cess,  and  in  this  respect  gonorrhea  of  the  uterus  differs 
from  septic  endometritis  which  may  from  the  first  be 
devoid  of  acute  symptoms. 

In  no  form  of  purulent  endometritis  do  I  ever  make 
applications.  These,  while  destroying  pyogenic  cocci, 
also  kill  the  superficial  cells  of  the  endometrium  and 
furnish  no  means  for  the  escape  of  the  destroyed  tissue. 
The  history-books  of  all  of  us  bear  many  cases  where 
acute  pelvic  inflammations  have  resulted  from  intra- 
uterine applications. 

TUBERCULAR  ENDOMETRITIS. 

Tubercular  disease  of  the  cervix  is  exceedingly  rare, 
the  disease  being  usually  limited  to  the  body  of  the 
organ.  But  it  is  occasionally  met  with,  and  then  is 
secondary  to  vaginal  tuberculosis.  Occurring  in  the 
cervix  the  disease  is  either  miliary  or  ulcerative,  and  is 
not  often  diagnosticated  without  the  aid  of  the  micro- 
scope ;  the  miliary  tubercles  being  mistaken  for  small 
cervical  cysts  and  the  ulcers  for  carcinoma. 

It  is  rare  to  find  the  cervix  and  corpus  uteri  involved 
in  the  same  individual ;  the  uterus  being  affected  second- 
arily, the  cervix  from  the  vagina,  the  endometrium  from 
the  peritoneal  face  of  the  uterus. 

Syuiptoms. — Tubercular  endometritis  produces  pro- 
fuse leucorrhea  which  may  contain  caseous  masses.  The 
uterus  is  enlarged.  Where  menstruation  occurs  it  is 
irregular  or  profuse,  but  the  concomitant  cachexia  gen- 
erally produces  amenorrhea  in  the  later  stages.  Other- 
wise the  symptoms  are  those  of  chronic  endometritis, 
plus  the  general  symptoms  of  general  tuberculosis  where 
that  exists. 

Diag-iiosis. — Without  finding  the  tubercle  bacillus,  a 
positive  diagnosis  is  impossible.  It  is  not  necessary  to 
excise  portions  of  ulcerating  tissue ;  the  discharge  will 
show  the  bacillus. 

Treatment. — Whenever  a  diagnosis  can  be  made,  ex- 
section  of  the  affected  portion  is  indicated  if  it  possibly 


ENDOMETRITIS.  e^ 

Can  be  done.  Tlie  cervix  without  a  tendency  for  the 
disease  to  extend  upwards,  may  be  amputated.  But 
paihative  treatment  can  not  be  applied  to  the  corpus 
uteri,  and  curettage  alone  will  not  check  the  disease. 
Total  vaginal  extirpation  of  the  uterus  and  adnexa  is  in- 
dicated, both  because  the  uterine  disease  is  commonly 
secondary  to  adnexal  tubercular  disease,  and  because 
extirpation  of  the  tubercular  uterus  works  such  mar- 
vellous changes  in  the  metabolism  of  the  blood  as  to 
hold  in  abeyance  for  years  tubercular  lung  disease.  Be- 
cause of  local  and  general  reasons,  if  I  may  so  term 
them,  hysterectomy  is  indicated  in  corporal  tuberculosis. 
Any  other  operative  procedure  but  plays  with  the  dis- 
ease, opening  new  channels  for  its  extension.  Local 
treatment  is  useless.  Excision  is  the  treatment  for 
tubercular  disease  of  the  genitals.  I  have  seen  a  phthisi- 
cal woman  gain  thirty  pounds  in  two  months  after  this 
operation.  No  one  who  has  not  estimated  the  quantity, 
often  ounces  a  day,  of  discharge  coming  from  these 
women  can  have  any  idea  of  the  drain  upon  their 
systems. 

The  failure  of  agents  lauded  as  corrective  of  tubercu- 
losis to  even  modify  the  disease  when  the  organ  is  within 
easy  access  and  the  treatment  applied  under  the  eye,  is 
a  commentary  upon  the  methods  of  reasoning  of  those 
who  advocate  them. 

Sequelae. — When  occurring  as  a  primary  disease, 
uterine  tuberculosis  will  surely  extend  to  the  peritoneum 
and  adnexa,  to  be  followed  by  general  tuberculosis. 


54 


PELVIC    INFLAMMATION. 


PELVIC    INFLAMMATION. 

Up  to  a  few  years  ago  it  was  undoubtedly  the  practice 
with  most  surgeons  to  remove  through  the  abdomen  all 
ovaries  and  tubes  which  presented  evidences  of  inflamma- 
tion, whether  these  were  diseased  primarily,  or  as  the 
result  of  a  lymphatic  infection  in  the  pelvis.  So  long 
as  this  remained  the  established  rule  of  procedure  in 
dealing  with  tubo-ovarian  disease,  precise  differentia- 
tion of  the  various  lesions  was  not  necessary.  But  a 
more  careful  study  of  the  manner  in  which  the  gross 
lesions  were  produced,  together  with  the  application  of 
those  general  surgical  principles  which  govern  the  treat- 
ment of  inflammatory  lesions  elsewhere,  has  taught  us 
the  necessity  for  carefully  separating  those  lesions  which 
necessitate  the  removal  of  the  diseased  organs  from  those 
which  are  relieved  by  conservative  measures.  It  there- 
fore becomes  our  duty  to  enter  into  a  thorough  analysis 
of  each  case.  To  do  this  it  is  not  essential  to  a  proper 
conclusion  that  a  bacteriological  examination  be  made, 
but  the  correct  treatment  can  be  reached  by  studying 
the  clinical  history  of  each  case.  Although  the  ovaries 
and  tubes,  as  well  as  the  pelvic  peritoneum,  will  probably 
suffer  in  most  cases  where  the  infection  passes  outside 
the  uterus,  yet  all  the  structures  will  not  be  equally 
damaged.  The  manner  in  which  the  infection  reaches 
the  pelvic  structures  as  well  as  its  nature  will  indicate 
somewhat  the  organ  we  will  find  most  affected.  In  all 
infections,  for  instance,  occurring  in  the  uterus  pregnant 
after  the  third  month,  those  lesions  which  result  from 
pelvic  peritonitis  are  to  be  expected,  for  in  such  a  uterus 
the  lymph  streams  and  not  the  tubes  are  the  chief  car- 
riers of  the  infecting  agents.  And  inasmuch  as  the 
poison  of  gonorrhea  travels  not  through  the  lymphatics, 
but  through  direct  continuity  of  tissue  along  the  uterus 


PELVIC   INFLAMMATION. 


55 


and  Fallopian  tubes,  this  may  usually  be  eliminated  as  a 
cause  of  the  trouble,  and  the  case  be  set  down  as  due  to 
sepsis.  As  a  result  we  have  produced  the  effusion  of 
lymph  on  the  peritoneum,  suppuration  in  the  folds  of  the 
broad  ligaments,  or  ovarian  abscess,  one  or  all.  (Second- 
arily salpingitis  may  result.)  Conversely,  in  a  uterus 
with  undeveloped  lymphatics,  that  is  in  the  unimpreg- 
nated  uterus,  the  invasion  is  usually  through  the  tubes, 
and  may  be  either  gonorrheal  or  septic.  The  resulting 
lesions  are  salpingitis  with  secondary  involvement  of  the 
periton.eum  and  perhaps  of  the  ovary.  Furthermore 
the  results  of  these  various  kinds  of  infection  may  be  of 
a  purulent,  a  cystic,  or  even  a  connective-tissue  type.  To 
characterize  all  these  lesions  as  merely  "tubo-ovarian 
disease  "  is  to  subject  them  all  to  one  method  of  treat- 
ment, removal. 

The  diffuse  peritonitis  due  to  abortion  is  cured  in  the 
same  way  as  the  pleurisy  due  to  rib  necrosis,  by  scrap- 
ing away  the  infected  focus  ;  cysts  of  retention,  as  cystic 
ovary  and  hydrosalpinx,  are  to  be  treated  as  similar 
accumulations  elsewhere,  that  is  by  evacuation.  Puru- 
lent accumulations  here  behave  exactly  as  elsewhere  in 
the  body.  If  found  in  preformed  sacs,  as  the  tubes,  they 
are  cured  by  removal  or  by  evacuation  and  obliteration. 
If  seated  in  the  continuity  of  tissue,  as  in  the  ovary  or 
broad  ligament,  evacuation  will  cure.  But  the  situation 
of  the  diseased  focus,  whether  high  up  or  low  down,  will 
influence  the  method  of  operating;  for  the  element  of 
drainage  bears  a  most  important  part  in  all  such  work, 
I  mention  these  facts  briefly  to  emphasize  the  importance 
of  carefully  considering  each  case  upon  its  merits,  and  to 
show  the  utter  folly  of  laying  down  hard  and  fast  rules 
for  dealing  with  the  several  lesions.  We  formerly  heard 
much  about  "cellulitis."  Cellulitis  does  not  occur  in 
the  tubes,  that  is,  suppuration  is  not  found  in  the  tubal 
walls  except  as  consecutive  upon  more  marked  suppura- 
tion in  their  cavities.  Suppuration  between  the  folds  of 
the  broad  ligament  is  not  cellulitis.  The  pus  is  not  pro- 
duced in  the  thin  cellular  layer  of  the  ligament,  but  in  its 


56 


PELVIC   INFLAMMATION. 


lymphatics.  Broad  ligament  "cellulitis"  is  broad  liga- 
ment lymphangitis.  The  only  true  cellulitis  found  in 
the  pelvis  is  that  which  is  seen  in  the  ovarian  stroma. 
There  may  be  effused  about  the  broad  ligament  a  large 
mass  of  lymph  as  a  result  of  lymphangitis  between  the 
folds  of  the  ligament,  and  suppuration  in  such  an  accu- 
mulation may  simulate  "  cellulitis."  Even  when  applied 
to  ovarian  suppuration,  the  term  is  misleading.  It  should 
have  no  place  in  our  nomenclature  of  pelvic  lesions,  and 
I  do  not  accept  it  as  descriptive  of  any  lesions  I  have 
ever  seen  in  the  woman's  pelvis.  Migration  of  cells 
takes  place  in  the  pelvic  structures  because  of  invasions 
from  without.  If  the  cells  die,  pus  is  produced.  The 
generalization  "  cellulitis  "  is  meaningless.  Pyosalpinx, 
ovarian  abscess,  pelvic  peritonitis,  are  precise  statements 
of  gross  lesions,  and  gross  lesions,  not  microscopic 
changes,  are  the  basis  for  our  operations. 

The  great  advance  made  in  the  treatment  of  pelvic  in- 
flammatory lesions  is  due  to  our  knowledge  that  they 
are  produced  by  exactly  the  same  agents  as  cause  inflam- 
mations elsewhere.  Cold  feet,  fright,  menstruation,  etc., 
have  ceased  to  be  causes  for  pus  in  the  pelvis,  although 
used  as  excuses  for  unclean  surgical  operations  and  infi- 
delity. 

Certain  germs  produce  certain  lesions  under  certain 
conditions.  The  pathology  of  pelvic  inflammations  is  as 
accurate  as  any  other,  and  upon  an  accurate  knowledge 
of  the  causative  germs,  the  conditions  under  which  they 
exist,  and  their  paths  of  extension,  will  depend  the 
proper  treatment  of  the  results  of  their  activity. 

This  precise  differentiation  of  the  conditions  under 
discussion  cannot  always  be  made  upon  examination,  but 
the  cul-de-sac  exploration  will  clearly  show  them. 

Starting,  then,  with  the  history  of  the  case  and  the 
data  furnished  by  carefully  kept  clinical  notes  and  re- 
peated examinations,  we  are  in  a  position  to  determine 
the  propriety  of  operative  interference.  And  the  sur- 
geon will  decide  whether  his  attention  should  be  limited 
to  the  uterus  alone  or  whether  the  adnexa  should  be  at- 


TELVIC   INFLAMMATION. 


57 


tacked.  In  the  latter  event  the  exploratory  part  of  the 
operation  can  be  made  as  satisfactorily  through  the  va- 
gina as  through  the  belly  and  with  far  less  risk  to  the 
patient.  Meeting  with  certain  conditions,  the  vaginal 
section  can  be  made  a  curative  operation  without  removal 
of  any  organs  and  without  risk.  This  much  cannot  be 
said  of  laparotomy. 

All  these  questions  are  brought  under  discussion  in 
the  proper  places. 

Diag-iiosis. — Before  attempting  to  proceed  with  any 
method  of  treatment,  it  is  essential  to  determine  that  the 
case  is  one  of  inflammation  of  the  generative  organs. 
The  diseases  with  which  pelvic  inflammation  is  most  com- 
monly confounded  are  :  appendicitis,  ureteral  inflamma- 
tion, acute  cystitis,  general  peritonitis  and  suppurating 
ovarian  cyst. 

Appendicitis. — This  cannot  be  mistaken  for  pelvic  in- 
flammation of  course,  except  where  the  disease  is  on  the 
right  side.  The  pain  of  appendicitis  is  usually  situated 
somewhere  about  a  line  drawn  from  the  umbilicus  to  the 
anterior  superior  spine  of  the  ilium.  Pain  due  to  tube 
ovarian  disease  is  commonly  much  below  this.  The  sen- 
sitiveness to  touch  in  appendicitis  is  greatest  when  pres- 
sure is  made  upon  the  belly  over  the  caecum,  while 
greatest  pain  in  adnexal  disease  is  developed  by  vaginal 
examination.  The  pain  due  to  appendicitis  radiates  up- 
ward toward  the  hypogastric  region,  while  that  due  to 
tubo-ovarian  disease  extends  downward  toward  the  pu- 
bic region  of  the  pelvic  cavity.  In  appendicitis  disturbed 
bowel  function  frequently  precedes  the  attack,  while  it 
follows  salpingitis,  if  it  occurs  at  all.  Symptoms  of  col- 
itis often  accompany  appendicitis,  while  they  are  absent 
with  tubal  disease.  Tympanites  is  usual  in  appendicitis, 
the  distention  being  general,  while  in  pelvic  inflammation 
it  is  usually  limited  to  the  colon.  In  appendicitis  there 
is  absence  of  signs  of  genito-urinary  inflammation,  such 
as  endometritis,  urethritis,  etc. ;  while  some  one  of  these 
is  present  with  salpingitis.  Very  often  tubo-ovarian  dis- 
ease coexists  with  appendicitis,  and  the  inflamed  organs 


58 


PELVIC   INFLAMMATION. 


may  be  matted  together  in  one  indistinguishable  mass. 
In  such  cases  the  operator  must  consider  the  lesions  as 
abdominal  rather  than  pelvic.  Appendicitis  does  not 
cause  fixity  of  the  uterus,  and  digital  search  in  the  vagina 
does  not  increase  the  pain  of  appendicitis.  The  con- 
trary is  true  where  pelvic  inflammation  exists.  But  ap- 
pendicitis may  coexist  with  pelvic  inflammation.  As 
the  abdominal  symptoms  will  predominate  over  the  pel- 
vic a  suspicion  of  the  appendicitis  must  be  held.  Such 
cases  are  to  be  viewed  from  the  abdominal  side  if  the 
cul-de-sac  exploration  fails  to  clear  up  the 'diagnosis. 

Cystitis. — Ardor  urinje,  blood  or  pus  in  the  urine,  pain 
on  urination,  suprapubic  sensitiveness,  infrapubic  tender- 
ness, mark  cystitis.  In  cystitis  vaginal  examination  does 
not  develop  pain  except  where  the  space  anterior  to  the 
uterus  is  pressed  upon.  In  pelvic  peritonitis  the  lateral 
fornices  are  most  sensitive.  Again,  in  pelvic  peritonitis 
there  is  not  marked  disturbance  of  bladder  function, 
while  in  cystitis  there  is,  and  there  is  usually  pronounced 
inflammation  of  the  uterus  in  cases  of  peritonitis  which 
which  is  not  present  in  cystitis.  The  uterus,  tubes,  ova- 
ries and  peritoneum  are  uninvolved  in  cases  of  cystitis. 

Ureteritis. — Inflammation  of  the  ureters  is  usually  sec- 
ondary to  cystitis.  A  careful  urinalysis  will  show  pus, 
ureteral  epithelium  and  often  blood  in  the  urine  drawn 
by  catheter.  There  is  the  same  pain  in  the  lateral  pelvic 
walls  as  is  found  in  adnexal  disease,  but  there  is  no  fixity 
of  the  uterus,  and  moving  the  uterus  with  the  finger  does 
not  increase  the  pain.  Ureteral  calculi  cause  spasmodic 
pain  similar  to  that  of  acute  salpingitis,  but  it  radiates 
down  to  the  urethra,  produces  bloody  urine,  and  the 
spasm  is  often  accompanied  by  involuntary  discharge  of 
urine.  The  pain  of  pelvic  peritonitis  is  constant,  and  the 
fever  produced  by  tubal  inflammation  is  usually  higher 
than  that  seen  with  cystitis  and  ureteritis. 

Siippurating  Ovarian  Cyst. — There  is  the  same  mass, 
tenderness  and  fixity  as  accompany  tubal  disease.  In 
fact,  the  symptoms  produced  by  such  a  cyst  are  more 
due  to  the  concomitant  peritonitis  than  to  the  cyst.      It 


PELVIC   INFLAMMATION. 


59 


is  exceedingly  difficult  to  differentiate  between  a  large 
pyosalpinx  or  ovarian  abscess  and  a  small  inflamed  ovar- 
ian cyst.  If  the  cyst  is  of  sufficient  size  it  will  press  the 
uterus  upward  and  forward,  whereas  a  large  adnexal 
abscess  will  displace  it  laterally. 

Haste  in  making  examinations  will  lead  the  surgeon 
into  many  errors.  I  have  seen  a  good  man  cut  open 
the  belly  for  typhoid  fever  in  a  woman  with  gonorrhea, 
thinking  he  had  tubal  disease  to  deal  with. 

From  what  has  been  said,  it  will  be  seen  that  the  seat 
of  pain  and  its  character  are  invaluable  in  making  a 
diagnosis.  Therefore,  opiates  are  not  to  be  used  until 
the  diagnosis  is  clearly  made,  if  at  all.  I  have  laid  some 
stress  upon  the  evidence  of  disease  as  developed  by  the 
cul-de-sac  operation.  This  exploratory  procedure  being 
free  from  danger,  and  occupying  but  a  few  minutes 
time,  can  be  resorted  to  where  a  positive  diagnosis  is 
necessary.  Lesions  being  by  it  revealed,  the  removal  of 
which  would  endanger  life  or  is  forbidden,  the  operator 
can  not  only  retreat  without  having  damaged  his  patient, 
but  in  most  cases  of  pelvic  disease,  he  will  afford  some 
measure  of  relief  by  that  operation  alone.  Such  can  not 
be  said  of  the  abdominal  section. 

General  Suppurative  Peritonitis. — In  some  cases  of 
diffuse  pelvic  suppuration,  with  sudden  and  sharp  exten- 
sion of  the  infection,  it  will  be  hard  to  differentiate  be- 
tween a  local  and  a  general  infection  of  the  peritoneum. 
General  purulent  peritonitis  produces  great  shock.  The 
pulse  is  generally  above  120,  the  temperature  ranging 
about  103°.  Tympanites  is  pronounced,  vomiting  in- 
cessant; restlessness,  sordes  on  teeth  and  lips,  dry, 
cracked -tongue,  mental  anguish,  pinched  face,  muscular 
twitchings  and  delirium,  mark  general  peritonitis.  As 
each  hour  passes  the  symptoms  become  rapidly  more 
grave.  There  is  no  remission.  Without  an  examina- 
tion, the  experienced  physician  can,  by  carefully  study- 
ing the  symptoms,  determine  whether  the  case  is  one  of 
localized  lesions,  with  severe  general  symptoms,  or  one 
of  general  peritonitis.     Examination  will  be  of  little  ser- 


Co  PET.VIC   INFLAMMATION. 

vice  in  making  a  differential  uiagnosis  between  local  and 
general  peritonitis.  I  have  seen  at  ten  in  the  morning  a 
case,  apparently,  of  bilateral  pyosalpinx  due  to  abortion, 
which  when  operated  upon  at  three  in  the  afternoon  was 
almost  moribund.  Certain  cases  of  virulent  pelvic  in- 
flammation will,  in  a  few  hours,  become  general  through- 
out the  peritoneal  cavity.  This  is  especially  true  of 
cases  of  post-partum  and  post-abortum  infection. 

General  peritonitis  is  one  of  the  results  to  be  expected 
from  a  policy  of  delay.  The  vomiting,  rapid  pulse,  dry 
tongue,  stupor  and  tympanites,  which  result  from  the 
use  of  opiates  in  a  grave  case  of  pelvic  inflammation  will 
often  render  a  diagnosis  of  the  extent  of  the  infection 
utterly  impossible.  The  cases  where  surgeons  have 
opened  the  belly  and  found  all  the  disease  in  the  pelvis 
are  many.  The  surest  way  to  mask  the  symptoms  of 
pelvic  inflammation  is  to  give  opium. 

Treatment. — Opiates. — These  I  rarely  use  and  for  a 
number  of  reasons.  To  relieve  pain  by  opiates  is  to 
mask  the  symptoms  of  extension  and  complications. 
The  bowels  become  blocked,  and  this  permits  the  migra- 
tion of  the  intestinal  germs ;  the  stomach  is  deranged, 
and  the  bladder  function  disturbed.  Brought  to  a  case 
of  pelvic  inflammation,  if  he  contemplates  possible  oper- 
ation, the  surgeon  should  withhold  opiates.  Other 
means  are  at  his  command  to  ease  pain,  and  the  relief 
afforded  by  opiates  is  but  a  borrowed  ease,  to  be  paid 
back  by  vomiting,  tympanites,  and  spread  of  the  in- 
fection. 

Intestinal  Cleanliness. — From  the  first  I  insist  upon 
this.  Placing  the  patient  upon  the  left  side  with  the  hips 
elevated,  I  insert  a  Martin's  tube  (Fig.  13)  and  throw 
into  the  bowel  a  quart  of  tepid  normal  salt  solution. 
Part  of  this  is  retained.  To  obtain  retention  the  injec- 
tion should  be  given  at  night,  or  when  the  bowels  do 
not  habitually  operate.  This  cleanses  out  the  colon, 
flushes  the  kidneys  and  allays  thirst.  I  do  this  each 
night.  The  maneuvre  is  very  simple.  The  outflow  tube 
is  corked  up,  and  the  fountain  syringe  is  raised  four  feet 


PELVIC   INFLAMMATION.  6l 

above  the  bed.  The  water  should  be  of  a  temperature 
of  103°  to  105°  F.  These  irrigations,  by  removing  hard 
fecal  masses,  and  relaxing  muscular  spasm,  relieve  pain 
and  prevent  tympanites.  Purgatives  I  never  use,  but 
mild  cathartics,  as  an  ounce  of  Rubinat  water  every 
second  morning  in  a  glass  of  plain  water  an  hour  before 
breakfast,  I  employ. 

There  are  but  two  v/ays  of  treating  these  cavity  in- 
flammations :  the  locking-up  plan  (opiates),  and  the 
eliminative.  I  prefer  the  latter.  No  man  who  has  ever 
contrasted  the  two  will  accept  the  first. 

Douches. — Some  patients  express  themselves  as  re- 
lieved of  pain  by  douches,  others  dislike  to  be  disturbed. 


Fig.  13. — Martin's  tube  for  rectal  irrigation. 

But  they  are  demanded  where  there  is  much  discharge. 
I  prefer  to  use  lysol  )^  per  cent.,  at  a  temperature  of 
1 10°  F.,  every  four  hours. 

Abdominal  Dressings. — Poultices  cause  effusions  of 
blood  beneath  the  skin  and  vary  in  temperature  from 
90°  to  that  at  which  they  are  put  on.  I  prefer  to  use  an 
ice-bag  over  the  pubes.  It  is  easier  handled  and  relieves 
pain,  and  tends  to  limit  the  peritonitis  a  very  little. 

Fluids. — I  encourage  these  women  to  drink  large 
quantities  of  water.  A  good  plan  is  to  administer  three 
ounces  each  hour  when  awake.  Ten  drops  of  lemon 
juice  added  will  keep  the  tongue  clear.  Milk,  koumyss, 
etc.,  having  poor  food  value,  I  do  not  use.  Besides,  it  is 
difficult  to  get  rid  of  the  cheese  left  after  such  prepara- 
tions. Alcoholics  are  never  indicated.  In  women  deep 
in  infection,  and  with  bad  kidneys  and  thready  pulse,  I 
do  intravenous  infusion.  Anesthesia  is  unnecessary  for 
this.  (See  Article  on  Transfusion.)  Far  better  than  all 
drugs  is  this  procedure.     It  flushes  the  kidneys,  elimi- 


62  PELVIC   INFLAMMATION. 

nates  toxins  and  stimulates  the  heart.  The  amount  of 
urea  excreted  is  increased  and  the  albumen  diminished. 
The  effect  is  immediate. 

Diet. — Half  diet  is  indicated  in  mild  cases.  Farina, 
hominy,  an  egg,  and  a  little  coffee  for  breakfast;  a  little 
meat,  as  beef,  chicken,  chops,  etc.,  with  potatoes  and 
cream  at  midday  ;  chicken  soup  and  toast  at  four  o'clock ; 
and  squeezed  beef-juice  and  toast  at  eight.  But  all  the 
time  an  abundance  of  water. 

To  those  very  ill  I  do  not  give  solids.  In  the  morn- 
ing, toast,  and  a  very  little  coffee.  Once  every  three 
hours  after  that,  either  two  ounces  of  chicken  broth  or 
one  ounce  of  squeezed  beef-juice  is  given,  each  time  with 
a  little  toast.  No  milk.  To  those  who  vomit  continu- 
ously, I  give  nutrient  enemata.  Prepared  foods,  pre- 
digested  foods  and  fermented  foods  are  not  to  be  used. 

Local  Applications. — Pelvic  pain,  due  to  inflamma- 
tion, is  diminished  by  ice-bags  over  the  suprapubic  region. 
Spasmodic  pain  is  eased  by  poultices.  To  the  vagina, 
lo  per  cent,  ichthyol  in  glycerin,  applied  by  means  of  a 
syringe,  will  reduce  pain  and  act  beneficially  upon  the 
inflammation  at  all  stages.  Local  blood-letting,  applied 
to  the  cervix,  is  of  great  value  in  relieving  pain  and  vas- 
cular stasis. 

To  me,  the  free  purgation  used  by  some  is  as  bad  as 
the  opium  treatment.  All  that  is  needed  is  a  through 
and  through  stool  once  every  day  or  so,  but  the  colon 
must  be  kept  empty.  It  is  unwise  to  irritate  by  strong 
saline  cathartics  the  thirty  feet  of  intestinal  mucosa. 
Sepsis  in  the  pelvis  is  not  checked  by  it,  and  shock  is 
increased.  Perfect  rest  in  bed  is  imperatively  necessary. 
The  non-operative  treatment  of  pelvic  inflammations 
seeks  :  the  improvement  of  the  tissue-resistance  ;  limita- 
tion of  the  infecting  agent;  and  maintenance  of  the  gen- 
eral strength  while  the  invaded  organs  are  overcoming 
the  infection. 


SALPINGITIS. 


63 


SALPINGITIS. 

Gonorrheal  Salpingitis      |  chronic 

Septic  Salpingitis  }  chronic. 

Tubercular  Salpingitis       |  Chronic. 

ACUTE  GONORRHEAL  SALPINGITIS. 

The  causative  germs  are  gonococci.  These  may  have 
entered  fresh  from  an  acute  clap  in  the  male,  or  from  a 
gleet,  or  may  be  the  result  of  a  rekindling  of  the  spark 
which  has  for  some  time  been  dormant  and  latent  in 
some  other  part  of  the  genito-urinary  tract  of  the  woman 
(Fig.  14).  The  disease  is  usually  bilateral,  though  differing 
often  in  severity  upon  the  two  sides.  The  first  stage  is  one 
of  congestion  and  edema.  When  the  infection  reaches 
the  fimbriated  end,  a  local  peritonitis  results.  The  pe- 
ritonitis is  secondary  to  the  salpingitis,  because  the  gon- 
orrhea travels  through  the  tubes  and  not  through  the 
lymphatics.  The  fimbriae  of  the  affected  tube  turn  in 
and  their  peritoneal  surfaces  cohere,  owing  to  a  circum- 
scribed peritonitis  about  the  fimbriae.  Thus  the  tubal 
contents  become  locked  in,  and,  secretion  continuing,  a 
cyst  of  retention  is  formed  (Fig.  15).  Usually  this  latter  is 
a  pyosalpinx,  occasionally  a  hydrosalpinx.  Or,  the  secreted 
fluids  may  become  almost  wholly  absorbed  and  the  con- 
dition be  marked  by  the  production  of  new  connective 
tissue  in  the  walls  of  the  tube,  which,  contracting,  con- 
stitutes tubal  sclerosis.  Sclerosis  with  hydrosalpinx,  or 
with  pyosalpinx,  is  very  common. 

In  the  first  or  acute  stage,  the  tube  is  deeply  discol- 
ored and  easily  torn.  It  may  measure  as  much  as  an 
inch  in  diameter.     Upon  section  the  lumen  is  found  not 


64 


PELVIC   INFLAMMATION. 


much'  distended  and   the  increase  in  size  is   due  to  sub- 
mucous infiltration. 

The  tissues  are  so  swollen  that  the  rugae  are  almost 


:^^ 


ll^ 


Fk;.  14. — Section  of  the  normal  Fallopian  tube  near  the  abdorninal  ostinm 

(Beyea). 

obliterated  as  separate  folds.  The  uterine  end  of  the 
affected  tube  is  still  patent,  and  the  creamy  purulent 
contents  of  the   tube  escape    into  the    uterine    cavity. 


SALPINGITIS. 


65 


After  a  time  the  uterine  end  of  the  tube  is  also  closed, 
and  there  is  formed  a  permanent  fluid  accumulation  in 
the  tube.  The  tube  may  be  knotted  and  twisted  or 
sausage-like.  Spontaneous  cure  is  rare,  the  case  usually- 
resulting  in  some  permanent  deformity.  The  heavy  tube 
is  prone  to  sink  down  behind  the  broad  ligament.  Com- 
monly the  adjacent  ovary  as  well  as  the  pelvic  peritoneum 
is  involved. 


Fig.  15. — Longitudinal  section  of  Fallopian  tube,  exposing  the  complicated 
longitudinal  plications  of  the  mucosa  which  expand  into  the  fimbriae  (Sappey). 


Symptoms. — Added  to  the  symptoms  of  acute  gonor- 
rheal endometritis  we  have  certain  others.  In  addition 
to  the  uterine  pain  and  cramps  are  pains  originating  in 
the  neighborhood  of  the  tubes  and  shooting  down  the 
thighs  or  upward.  There  is  also  pain  in  the  sacroiliac 
region.  Spasm  of  the  affected  part  is  common,  I  find, 
before  peristalsis  is  stopped  by  the  intensity  of  the  in- 
flammation The  temperature  (rectal)  may  reach  103°  F. 
and  the  pulse  nearly  120,  but  commonly  the  pulse  is 
below  no.  There  is  often  vomiting  and  nausea.  Tym- 
panites and  costiveness  are  common.  The  symptoms 
are  most  severe  before  the  stage  of  stasis,  that  is,  up  to 
the  fifth  day.    They  then  usually  begin  to  subside  some- 

5    . 


66  PELVIC   INFLAMMATION. 

what  and  the  case  resolves  into  some  one  of  the  chronic 
forms.  Upon  vaginal  examination  the  lateral  pelvic 
walls  are  found  tense  and  the  uterus  fixed  by  plastic  ef- 
fusion and  tubal  enlargement.  The  lateral  fornices  are 
exquisitely  sensitive  and  a  thorough  examination  may 
be  impossible  without  narcosis.  In  seeking  the  enlarged 
tube,  the  viscera  above  are  supported  by  a  firm  steady 
pressure  of  the  palmar  surfaces  of  the  fingers  applied 
over  the  ovarian  region.  One  finger  is  inserted  into  the 
vagina  and  the  cervix  found.  The  finger  is  then  crowded 
high  up  alongside  the  uterus,  and  as  it  is  swept  out  to- 
ward the  pelvic  wall  it  will  feel  the  tube  roll  over  it. 
The  tube  is  not  very  movable,  and  where  marked  fixation 
exists  the  finger  can  very  accurately  determine  its  size. 
The  physician  should  stand  at  the  patient's  side,  she 
being  in  the  lithotomy  posture.  Placed  in  this  way  he 
can  pronate  and  supinate  his  hand  so  as  to  feel  all  parts 
of  the  pelvis. 

Upon  opening  the  cul-de-sac  there  is  usually  at  once 
an  escape  of  serum  containing  flakes  of  lymph.  When 
the  examining  finger  is  inserted  (see  cul-de-sac  explora- 
tion) it  appreciates  the  presence  of  recently  effused  lymph, 
for  the  rectum  is  often  found  attached  to  the  posterior 
surface  of  the  uterus  by  tender  union,  and  the  inflamed 
tubes  are  sealed  to  whatever  structures  they  rest  against, 
usually  the  broad  ligaments.  If  the  affected  tube  is  low 
down,  it  is  felt  to  be  a  rounded  firm  yet  elastic  mass, 
extending  from  one  cornu  of  the  uterus  to  the  ovary  or 
broad  ligament.  To  one  of  these  it  is  usually  attached 
at  its  fimbriated  end.  At  the  cornu  the  tube  is  small, 
but  as  the  free  end  is  reached  it  is  found  to  enlarge  into 
a  blunt  knob.  The  false  union  between  the  tube  and 
other  structures  is  easily  severed  by  the  finger,  and  this 
produces  slight  parenchymatous  oozing.  Upon  freeing 
the  tube  and  ovary  from  abnormal  attachments  they  can 
be  brought  into  view  at  the  vaginal  vault.  To  accom- 
plish this  it  is  better  to  introduce  a  gauze  pad  above  the 
affected  tube  and  then  draw  down  the  tube  below  the 
pad.     In   manipulating  the  tube  the  finger  only  should 


SALPINGITIS. 


67 


be  used,  as  instruments  tend  to  break  the  swollen  and 
friable  structure.  The  gauze  pad  keeps  the  intestines 
above  the  vagina,  but  if  these  continue  to  prolapse  into 
the  vagina  the  table  may  be  lowered.  Upon  inspecting 
the  tube  it  will  present  the  signs  of  intense  inflammation 
described  at  the  first  of  this  chapter. 

Diag-iiosis. — There  are  nearly  always  present  other 
evidences  of  gonorrhea,  and  in  most  cases  the  pus  from 
the  uterus  shows  the  gonococcus  to  be  present.  The 
various  pelvic  neuralgias  are  devoid  of  the  symptoms  of 
acute  inflammation,  general  as  well  as  local. 

Ectopic  gestation  in  the  early  months  may  present  the 
same  symptoms  of  pain,  a  mass,  and  tenderness;  but  in 
ectopic  gestation  there  are  not  acute  purulent  endome- 
tritis, erosions,  fever,  etc.  Inspection  through  the  cul- 
de-sac  will  positively  determine  the  question  of  the  exist- 
ence of  acute  salpingitis. 

Treatment. — As  soon  as  a  gonorrheal  process  has 
passed  outside  the  uterus  involving  the  tubes  and  pelvic 
peritoneum,  the  disease  has  progressed  too  far  to  be 
cured  by  any  form  of  treatment  applied  solely  to  the 
uterus.  It  is  necessary  to  attack  the  complications. 
The  uterus  is  curetted  (see  curettage).  After  this  is 
done  the  posterior  cul-de-sac  is  opened.  If  this  explora- 
tor)'  incision  shows  that  both  adnexa  are  involved,  one 
of  two  courses  may  be  taken  :  either  break  up  all  the 
adhesions,  split  open  the  tubes  (see  conservative  treat- 
ment) and  pack  the  pelvis  with  gauze,  or  also  make  a 
vaginal  ablation.  Merely  opening  the  tubes  and  swab- 
bing them  out  with  iodoform  gauze  will  suffice  in  cases 
in  the  acute  stage  and  before  pus  has  become  encapsu- 
lated within  them.  Of  course  the  pelvic  peritoneum  is 
exposed  to  the  dripping  from  the  tubes,  but  this  is 
caught  by  the  gauze.  If  distinct  pus  sacs  have  already 
formed,  they  are  to  be  treated  as  described  under  chronic 
inflammation.  My  experience  teaches  me  that  all  cases 
of  gonorrheal  tubal  disease  at  some  time  either  relapse 
or  become  reinfected.  To  always  do  an  ablation  is  to 
enter  the  dangerous  field  of  preventive  surgery.     I  pre- 


68  PET.YTC   INFLAMMATION. 

fer  in  most  cases  of  first  attack  to  perform  the  palliative 
operation,  aiding-  repair  by  evacuation  and  drainage  in  the 
acute  cases,  and  in  the  more  chronic  seeking  the  obliter- 
ation of  the  tubes  by  connective  tissue  hyperplasia  ;  and 
then  if  a  relapse  occurs  I  ablate.  Necessarily  the  woman's 
surroundings,  position  in  life  and  her  general  condition 
will  greatly  govern  my  action.  The  palliative  operation 
in  the  worst  cases  enables  the  operator  to  remove  the 
case  to  another  class  :  those  in  whom  an  elective  radical 
operation  can  be  performed,  with  all  that  that  means  to 
her  and  the  surgeon. 

If  upon  making  the  exploration  through  the  posterior 
cul-de-sac,  I  find  one  tube  alone  involved,  and  the  indi- 
cation is  apparently  clear  to  remove  it,  I  would  preferably 
perform  the  palliative  operation  (which  see) ;  or  else,  not 
do  a  laparotomy,  but  ablate  the  uterus  and  both  adnexa 
through  the  vagina.  The  relapses  are  so  frequent  where 
one  tube  is  removed  through  the  abdomen,  the  remain- 
ing one  becoming  infected  often  before  the  woman  leaves 
her  bed  after  the  first  operation,  that  I  cannot  lend  my 
endorsement  to  the  practice  of  abdominal  unilateral  sal- 
pingo-oophorectomy  in  these  cases.  I  am  clear  in  my 
conviction  that  we  must  either  be  wholly  conservative  or 
most  thorough  in  our  treatment.  (See  conservative  treat- 
ment). 

If  we  could  only  keep  these  women  away  from  men, 
the  ideal  operation,  one  with  permanent  results  so  far  as 
prevention  of  further  suppurative  processes  is  concerned, 
would  be  the  palliative  operation  through  the  cul-de-sac. 
But  the  unfortunate  creatures  will  return  to  the  husbands 
or  lovers  who  infected  them. 

Sequelae. — The  neglected  cases  go  on  to  the  formation 
of  either  a  sacculated  pyosalpinx  through  closure  of  both 
ends  of  the  tube,  or  a  sclerosis,  or  to  a  chronic  relapsing 
type  ;   rarely  does  hydrosalpinx  result  from   gonorrhea. 

If  the  currettage  and  cul-de-sac  operation  is  done  in  a 
first  attack  of  gonorrheal  salpingitis,  return  of  the  tubes 
to  a  normal  state  is  possible.  I  have  had  one  patient  on 
whom  this  operation  was  done  report  herself  pregnant. 


SALPINGITIS.  69 

But  where  gonorrhea  has  been  allowed  to  proceed  un- 
checked to  the  formation  of  a  pyosalpinx,  and  where  re- 
peated attacks  have  occurred,  which,  while  not  produc- 
ing pyosalpinx,  have  wrought  permanent  lesions  in  the 
walls  of  the  tubes,  the  cul  de-sac  operation  is  merely  pal- 
liative, and  the  restoration  of  the  tubes  is  but  partial. 

ACUTE  SEPTIC  SALPINGITIS. 

The  usual  causative  germs  are  staphylococci  or  strep- 
tococci (Fig.  16).  Sometimes  these  reach  the  tube  by  ex- 
tension along  the  lining  of  the  uterine  and  tubal  lining 
membranes.  In  most  cases,  however,  the  tube  is  involved 
subsequently  to  the  pelvic  peritoneum,  the  infecting 
process  first  reaching  the  pelvis  through  the  lym- 
phatics which  extend  from  the  uterus  between  the  broad 
ligaments  to  the  iliac  glands.  For  this  reason  we  most 
often  find  this  form  of  infection  following  interrupted  or 
completed  gestation,  for  in  this  state  the  lymph  streams 
are  sufficiently  developed  to  carry  the  infecting  agent. 
The  infection  is  more  apt  to  affect  one  tube  than  is  the 
case  with  gonorrhea.  The  lesions  induced  in  a  tube  so 
inflamed  are  identical  with  those  which  follow  gonorrhea. 

The  appearances,  both  gross  and  microscopic,  are  the 
same,  except  regarding  the  causative  cocci. 

Syniptonis. — Very  often  there  is  a  chill  ushering  in 
the  septicemia.  The  temperature  rises  rapidly  and  the 
pulse  is  disproportionately  high.  For  example,  the 
temperature  may  be  but  102°  and  yet  the  pulse  range 
from  120  to  140  beats  a  minute.  Local  pain  is  severe, 
at  first  spasmodic  in  the  uterus,  and  then  becoming  con- 
tinuous, as  the  general  pelvic  cavity  becomes  involved. 
Altogether  the  clinical  picture  is  not  significant  of  the 
cause  of  the  infection  except  that  it  is  more  commonly 
found  following  gestation  or  unclean  operations,  and  that 
the  examination  may  reveal  the  peritonitis  occurring  be- 
fore tubal  enlargement  can  be  appreciated. 

It  is  never  possible  without  the  use  of  the  microscope 
to  differentiate  positively  the  cause  of  the  inflammation. 


70 


PELVIC   INFLAMMATION. 


But  given  a  history  of  an  operation  upon  the  uterus,  or 
abortion,  or  labor,  followed  by  fever,   pain,  peritonitis, 


•-.  ..         '■■"'■'■  .J;.-fovS-. 


H. 


Fig.  i6. — Acute  septic  salpingitis.  Note  the  cellular  infiltration  in  the  walls 
of  the  tube  as  well  as  in  the  plications  of  the  mucous  membrane.  Section 
aljout  the  middle  of  the  tube  (Beyea). 

and  later  a  swollen  tube,  we  may  infer  that  the  case  is 
septic   and  not   gonorrheal.     This  inference  becomes  a 


SALPINGITIS. 


71 


Strong  probability  when  we  fail  to  find  signs  of  gonorrhea 
elsewhere,  notably  in  the  urethra  and  vulvo-vaginal 
glands;  and  the  diagnosis  is  rendered  certain  by  the 
microscopic  examination  of  the  discharge.  But  the 
possibility  of  mixed  infection  must  be  remembered,  for 
all  pyogenic  germs  may  be  in  the  same  case.  Upon 
bimanual  examination  the  same  signs  are  found  as  exist 
with  salpingitis  due  to  gonorrhea. 

The  cul-de-sac  incision  and  examination  do  not  aid  in 
differentiating  the  cause  of  the  salpingitis,  and  the  af- 
fected tube  presents  the  same  adhesions,  discoloration, 
swelling,  etc.,  as  are  found  in  gonorrheal  infection.  But 
there  is  apt  to  be  more  peritonitis  with  sepsis  than  with 
gonorrhea. 

Treatment. — Unimpregnated  Cases. — The  moment 
the  tube  or  the  peritoneum  shows  evidences  of  being  in- 
volved, the  uterus  should  be  curetted.  If  this  is  done 
before  there  is  actual  death  of  cells  with  the  formation 
of  pus,  a  cure  will  be  started  in  the  vast  proportion  of 
cases,  no  matter  how  extensive  the  peritonitis  may  be. 
The  first  indication  for  treatment  of  a  septic  uterus  with 
complications  short  of  the  formation  of  pus  is  the  re- 
moval of  the  causative  focus,  the  infected  endometrium 
or  decidua.  If  a  plastic  operation  has  caused  the  trouble, 
all  sutures  must  be  ripped  out  and  the  uterus  cleansed 
by  irrigation  with  boric  acid.  The  raw  surfaces  of  the 
wound  should  then  be  painted  with  pure  carbolic  acid. 

By  employing  this  curettage  early  more  women  have 
been  saved  needless  mutilating  operations  than  by  any 
other  treatment.  Suffice  it  to  say  that  the  ability  of  the 
tube  to  recover  after  the  causative  focus  is  removed  by 
curettage  is  far  greater  when  sepsis  starts  the  inflamma- 
tion, and  less  when  gonorrhea  is  the  cause. 

Still  here,  as  in  the  article  on  gonorrheal  salpingitis, 
the  rule  holds  good  to  open  the  cul-de-sac  in  addition  to 
curetting  in  all  cases  of  relapsing  septic  salpingitis  and 
in  those  seen  after  labor  or  abortion,  and  always  when 
evidences  of  pus  formation  are  present.  The  combined 
procedure  removes  the  diseased  endometrium  and  drains 


72 


PELVIC   INFLAMMATION. 


away  the  complications  in  the  pelvis.  Enormous  quan- 
tities of  muddy  toxins  escape  through  the  cul-de-sac 
gauze  in  such  cases,  showing  to  what  extent  the  lym- 
phatics are  drained.  The  technic  of  this  incision  and 
the  method  of  dressing  these  cases  are  found  in  an  appro- 
priate chapter. 

If  I  find  one  tube  only  involved  to  a  degree  which 
would  seem  to  warrant  its  removal,  I  always  apply  con- 
servative treatment  to  its  cavity,  and  do  not  debate  the 
propriety  of  its  removal.  If  I  find  both  tubes  acutely 
inflamed  in  a  first  attack  I  do  not  remove  them  or  con- 
sider ablation ;  for  I  have  seen  apparently  hopelessly 
involved  tubes  completely  recover  when  freed  and 
drained.  But  in  cases  many  times  before  infected,  and 
in  those  relapsing  after  conservatism  has  failed  to  cure, 
the  repair  power  is  so  damaged  that  it  is  unwise  to  at- 
tempt conservatism.  I  therefore  advise  the  radical  vagi- 
nal operation.  From  the  difference  between  the  treat- 
ment applied  to  the  gonorrheal  and  the  septic  cases  will 
be  seen  the  importance  of  a  differential  diagnosis. 

CHRONIC  SEPTIC  AND  GONORRHEAL  SALPINGITIS. 

Unchecked  septic  and  gonorrheal  infections  always 
leave  the  invaded  tube  permanently  damaged.  If  the 
tissues  have  marked  resistant  power  there  may  be  merely 
a  production  of  new  connective  tissue.  A  repetition  of 
the  infection  results  in  more  scar  tissue,  until  in  time  the 
tube  and  ovary  become  but  masses  of  cord-like  connective 
tissue, constitutingthe  condition  known  diS pachysalpingitis 
or  sclerosis  (Figs.  17,  18).  This  is  commonly  bilateral,  and 
the  process  frequently  involves  the  uterus.  Or,  for  some 
unknown  reason,  the  infection  merely  causes  occlusion  of 
both  the  fimbriated  and  uterine  ends  of  the  tube.  The 
tubal  secretion  is  retained,  and  the  tube  becoming  pro- 
gressively enlarged,  hangs  at  the  cornu  like  a  large  grape, 
with  thin  walls  and  clear  contents.  Sometimes  a  com- 
bination of  sclerosis  and  retention  is  met  with,  forming  a 
sacculated  hydrosalpinx  (Fig.  19).     I  have  found  much 


SALPINGITIS. 


73 


the  larger  number  of  hydrosalpinx  cases  to  be  due  to 
mild  sepsis  after  abortion  and  labor.  The  explanation  is 
that  sepsis  here  closes  the  fimbriated  end  of  the  tube, 
and  inflicts  but  slight  damage  upon  the  tubal  lumen. 

The  graver  results  of  pelvic  inflammation  are  pyosal- 
pinx  and  ovarian  abscess.    Very  frequently  we  find  them 


Fig.  17. — Chronic  salpingitis  witli  general  adhesions  of  tubes,  ovaries,  and 
uterus  (Bandl). 


associated  in  the  same  case.  The  tube  is  filled  with  pus, 
its  walls  thickened,  and  recent  lymph,  as  well  as  old  ad- 
hesions, are  found  upon  its  surface.  The  adhesions  are 
very  dense.  If  the  ovary  be  purulent,  there  may  be  one 
main  sac  with  the  ovarian  stroma  riddled  by  communi- 
cating sinuses  ;  or  the  pus  may  be  in  isolated  localities. 
These  organs  are  always  firmly  attached  to  the  adjacent 
structures.  The  longitudinal  .plicae  of  the  endosalpinx 
are  obliterated,  and  the  cavity  of  the  tube  is  lined  by  a 
roughly  granular  membrane,  "  pyogenic  membrane." 


74 


PELVIC   INFI^AMMATION. 


Sclerosis. — There  is  usually  a  history  of  many  attacks 
of  endometritis,  and  many  cases  have  been  subjected  to 
repeated  curettages.  The  menses  are  diminished.  Inter- 
menstrual leucorrhea  is  present,  but  is  not  profuse. 
There  is  continuous  pelvic  pain,  which  at  irregular  inter- 
vals is  exacerbated.  There  is  no  fever,  and  no  evidences 
exist  of  more  than  the  local  distress.  The  pain  is  severe; 
in  many  cases  the  women  appear  to  suffer  more  than  do 
pus  cases.     The  effort  to  menstruate  from  the  sclerosed 


Fig.  i8. — Removed  by  vaginal  ablation.     Pachysalpingitis  or  sclerosis.  * 


endometrium  produces  great  pelvic  tenesmus.  Most  of 
the  cases  are  stout.  Fever  and  acceleration  in  pulse  rate 
are  absent.  The  condition  is  exceedingly  common  in 
old  prostitutes.  Upon  examination  the  uterus  is  found 
atrophied  and  high  in  the  pelvis ;  it  is  fixed  there  by 
adhesions  and  not  by  plastic  or  other  masses  in  the  lateral 
fornices.  The  sides  of  the  vagina  are  drawn  to  the  cer- 
vix by  contraction  in  the  pericervical  tissues.  The  tubes 
can  be  felt  as  cords  extending  from  the  cornua  up  to  the 
pelvic  brim.  The  ovaries  cannot  often  be  felt.  Com- 
monly the  uterus  is  diminished  in  size,  but  often  cases  are 
met  with  where  the  organ  is  enlarged  (Fig.  20).     There 

*  The  wire  screens  used  in  these  illustrations  are  all  of  half-inch  mesh. 


<>•  S) 


F  -    ^ 


S 


SALPINGITIS. 


79 


is  a  fixity  about  these  uteri,  without  evidences  of  effusion, 
which  is  characteristic.  The  pain  is  produced,  not  by 
inflammatory  tension,  but  by  constriction  of  the  nerves 
by  connective  tissue.  Nature  has  employed  her  surest 
method  of  obHterating  the  affected  organs,  that  is  by 
connective  tissue  hyperplasia.  These  women  are  always 
sterile  (Fig.  21). 

Opening  the  cul-de-sac  is  difficult.  The  tissues  are 
firm  and  the  scissors  must  be  used  freely.  Even  when 
entered,  not  much  space  can  be  secured,  owing  to  the 
contracted  vaginal  vault.  There  are  commonly  felt  firm 
old  bands  between  the  contents  of  the  pelvis.    The  tubes 


Fig.  21. — A  case  of  genital  sclerosis  with  hypertrophy  of  the  corpus  uteri. 
From  an  old  prostitute  who  had  been  repeatedly  aborted.    Vaginal  ablation. 

can  be  traced  to  the  lateral  pelvic  walls,  or  lower,  behind 
the  broad  ligaments,  as  hard  cords.  They  are  freed  with 
difficulty;  in  fact,  sometimes  it  is  utterly  impossible  to 
release  them  at  this  point.  Upon  direct  inspection  they 
are  not  pink  as  in  health,  nor  brawny  as  are  pus  tubes, 
nor  livid  as  in  acute  salpingitis.  They  appear  as  firm,  pale 
cords,  sometimes  nodular.  The  ovaries  are  shrunken 
and  scar-like. 

Treatment. — A  cure  can  be  effected  by  ablation  only. 
Ichthyol  10  per  cent.,  on  tampons  or  injected  into  the 
vagina,  sometimes  relieves  the  pain.     The  lesions    are 


8o  TELVIC   INFLAMMATION. 

permanent  and  progressive.  The  cul-de-sac  incision  and 
conservative  treatment  afford  no  relief. 

Hydrosalpinx. — As  most  of  these  cases  follow  abor- 
tion or  labor,  there  may  be  elicited  a  history  of  perhaps 
mild  infection  at  that  time.  There  are  not  repeated 
attacks  of  peritonitis  arising  from  the  tube,  but,  of  course, 
an  affected  endometrium  may  give  rise  to  them.  Still, 
as  a  rule,  the  course  of  a  case  of  hydrosalpinx  is  more 
free  from  attacks  of  peritonitis  than  are  pus  cases.  There 
is  no  fever  and  no  continuous  pain.  Over-distention  ot 
adherent  bowels  produces  pain  in  the  tubal  locality. 
Women  may  have  large  dropsical  tubes  and  suffer  but 
little.  They  are  very  commonly  felt  when  examination 
is  made,  because  of  other  conditions,  as  retroversion. 
The  masses  are  not  very  sensitive,  are  not  firmly  attached 
by  lymph,  and  communicate  the  sensation  of  very  fluid 
contents.  Upon  opening  the  cul-de-sac  they  are  readily 
found  and  easily  freed  (Fig.  22).  Presenting  at  the  vagi- 
nal incision  they  appear  translucent  and  opalescent,  or 
perfectly  clear.  Their  sacs  are  transparent  and  exceed- 
ingly thin.  They  are  easily  ruptured  by  handling,  and 
can  be  confounded  with  subperitoneal  cysts  only.  Of 
course  they  are  attached  at  the  cornua,  and  may  exist 
as  single  large  cysts  or  as  sacculated  bunches  of  separate 
cysts  occupying  the  tube  cavity  (Fig.  23), 

Treatment. — They  are  to  be  treated  by  opening  the 
cul-de-sac,  freeing  the  sacs,  and  incising  them  with  scis- 
sors. As  the  clear  sterile  fluid  escapes,  it  is  caught  by 
gauze.  The  affected  tube  should  be  slit  open  for  an  inch. 
It  is  not  necessary  to  do  more.  The  tube  oozes  but  little 
after  incision  and  is  returned  into  the  pelvis.  Preferably 
the  incision  should  extend  from  the  fimbriated  end  along 
the  top  of  the  tube.  After  the  operation  is  finished  the 
cul-de-sac  is  plugged  with  gauze  which  extends  just 
within  its  cut  edges.  The  first  dressing  is  made  in  about 
eight  days.  No  fever  follows  the  operation.  These 
cysts  do  not  call  for  removal.  (See  conservative  cul-de- 
sac  operation.) 

Pyosalpinx. — This  is  a  purulent  cyst  of  retention  (Fig, 


Fig.  23. — Showing  a  hydrosalpinx  projecting  into  the  vagina  through  a  cul-de- 
sac  incision. 


SALPINGITIS. 


83 


24).  The  tube  is  more  dilated  near  its  fimbriated  end,  and 
at  the  cornu  of  the  uterus  it  is  quite  small  and  hard,  and 
its  lumen  obliterated  (Fig.  25).  Very  often  the  pus  tube  is 
associated  with  an  ovary  of  normal  appearance,  but  in 
most  cases  the  ovary  also  is  involved  in  the  mass  of  in- 
flammatory products,  sometimes  producinga  tubo-ovarian 


Fig.  22. — a,  a,  Hydrosalpinx.     A    lesion    readily  relieved   by    conservative 
operations  through  the  vagina  (Winckel). 


abscess.  There  are  commonly  many  adhesions  between 
the  tube  and  adjacent  organs.  Some  of  the  adhesions 
exist  as  old  bands,  but  recent  lymph  is  generally  always 
found. 

Symptoms. — These  are  essentially  those  of  acute  gon- 
orrheal or  septic  salpingitis  in  some  cases,  and  in  others 
there  are  no  subjective  symptoms  other  than  a  sense  of 
moderate  dscomfort.     Beyond  a  history  of  an  infection, 


84 


PELVIC   INFLAMMATION. 


with   possibly  the   presence  of  some  evidence  of  gonor- 
rhea, there  are  no  symptoms  different  from  those  found 


Fk;.  24. — An  old  pyosalpinw  (/,  Tlie  thickened  tubal  wall ;  b,  the  occluded 
fimbriated  end  ;  c,  the  tube  split  open,  showing  the  "  pyogenic  membrane  " 
(Winckel). 

in  other  suppurative   processes  in  the   pelvis.      Purulent 
endometritis  commonly  coexists. 


SALPINGITIS. 


85 


Upon  examination  of  a  case  of  salpingitis  which  has 
gone  on  to  the  formation  of  a  pyosalpinx,  the  uterus  is 
found  more  or  less  fixed.  On  the  infected  side  is  felt  a 
hard  yet  fluctuating  mass.  This  may  be  low  down  in  the 
cul-de-sac,  or  high  near  the  pelvic  brim  ;  usually  it  occu- 
pies a  position  somewhat  below  the  level  of  the  normal 
tube.  It  is  sensitive  upon  pressure,  the  pain  produced 
depending  largely  upon  the  acuteness  of  the  stage  of  the 
inflammation.     The  mass  is  felt  to  be  pedunculated,  that 


Fig.  25. — Bilateral  pyosalpinx.     Vaginal  ablation. 


is,  there  is  a  distinct  sulcus  between  it  and  the  uterus. 
This  is  not  always  so,  and  the  distended  tube  may  be 
closely  matted  to  the  posterior  and  lateral  walls  of  the 
uterus  by  plates  of  dense  exudate  (Fig.  26).  In  size  these 
pus-cysts  may  reach  the  dimensions  of  the  pelvic  cavity, 
crowding  the  uterus  deep  into  the  vagina,  or  high  up 
upon  the  brim  to  one  side.  Fluctuation  can  nearly  always 
be  detected.  In  eliciting  this  it  will  be  necessary  to 
firmly  support  the  tube  by  pressure  from  above  while  the 
vaginal  finger  determines  the  fluidity  of  its  contents. 
Usually  the  disease  is  bilateral,  the  common  association 
being  a  larger  tubal  abscess  upon  one  side  and  a  purulent 
salpingitis  on  the  other.  But  both  tubes  maybe  of  equal 
size.     If  the  sac  communicates  with  the  gut,  profound 


86 


PELVIC   INFLAMMATION. 


septicemia  may  set  in,  with  high  temperature  and  quick 
pulse.  Even  in  those  cases  devoid  of  acute  symptoms 
the  evening  temperature  is  higher  than  the  morning. 

Upon  opening  the  cul-de  sac,  the  finger  appreciates  the 
presence  of  dense  adhesions.  At  once  there  escapes  a 
variable  quantity  of  serum.  In  old  cases  the  cul-de-sac 
may  be  entirely  obliterated  and  the  finger  be  unable  to 
enter  except  high  up  on  the  posterior  surface  of  the 
uterus.     Sometimes  the  first  thing  felt  will  be  a  knuckle 


Fig.  26. — Right  pyosalpinx.     Left  pyosalpinx.     Vaginal  ablation. 


of  small  gut  or  of  omentum.  If  the  pus  tube  be  low 
down,  the  finger  will  reach  up  unobstructed  for  a  short 
distance,  and  then,  being  swept  out  to  one  side,  will  feel 
the  mass.  It  is  adherent  behind  the  broad  ligament, 
elastic  but  firm,  as  though  there  were  fluid  locked  within 
a  thick  capsule.  With  the  finger  circling  the  periphery 
of  the  tube,  it  is  gently  freed  below  and  will  then  be  felt 
attached  to  the  cornu  of  the  uterus  by  a  narrow  neck. 
These  tubes  vary  greatly  in  size  and  position.  Direct 
inspection  reveals  a  discolored  sac,  with  bleeding  points 
where  adhesions  have  been  severed,  and  flakes  of  lymph 


SAr.PINGITIS.  87 

covering  the  surface.  There  are  points  of  deep  injection. 
If  there  be  an  ovarian  abscess  alone  or  coexisting,  it  can 
be  differentiated  from  the  tube  only  by  tracing  its  attach- 
ments. Usually  an  ovarian  abscess  is  attached  higher 
than  a  pus  tube,  through  the  influence  of  the  infundibulo 
pelvic  ligament.  The  appearance  of  each  is  much  the 
same.  Ovarian  abscess  is  usually  firmer  and  more 
rounded  than  a  pus  tube.  Very  often  the  finger  imme- 
diately upon  penetrating  the  peritoneal  cavity  will  meet 
with  two  deeply  prolapsed  tubes,  the  peripheries  of  which 
are  agglutinated.  The  peritoneum  of  the  cul-de-sac  is 
much  thickened  and  often  must  be  severed  by  scissors. 
The  evidences  of  intense  inflammation,  its  attachments 
and  shape,  usually  that  of  an  elongated  pear,  will  deter- 
mine the  character  of  a  pus  tube.  If  the  trocar  be  plunged 
directly  into  the  mass  the  diagnosis  will  be  established 
by  the  escape  of  pus,  often  greenish  and  stinking,  or  even 
blood  stained. 

In  tubercular  pyosalpinx,  tubercles  may  often  be  seen 
upon  the  surface  of  the  sac.  Upon  the  right  side  very 
often  the  tube  is  attached  to  the  vermiform  appendix, 
and  at  all  points  the  omentum  and  small  intestines  may 
be  found  attached. 

Diagnosis. — There  are  a  history  and  evidence  of  infec- 
tion. A  suppurating  ovarian  cyst  is  usually  unilateral 
and  if  of  large  size  pins  the  uterus  up  against  the  pubes. 
An  ectopic  gestation  is  also  on  one  side,  is  harder  than  a 
pyosalpinx,  and  gives  subjective  symptoms  presumptive 
of  its  existence,  such  as  irregular  bleedings,  stabbing 
pains,  attacks  of  syncope^  etc.  Abroad  ligament  cyst  or 
abscess  is  always  sessile  upon  the  uterus,  giving  no  sulcus 
between  the  cyst  and  the  uterus,  and  is  always  situated 
laterally.  Broad  ligament  fibroids  are  of  cartilaginous 
hardness  and  are  also  sessile  upon  the  uterus.  All  broad 
ligament  growths  are  part  of  the  uterus  so  far  as  mobility 
is  concerned.  Exploratory  puncture  is  not  a  safe  pro- 
cedure, inasmuch  as  very  often  other  abdominal  contents 
lie  between  the  tube  and  the  vaginal  vault.  Besides, 
failure  to  find  the  pus  upon  puncture  is  no  proof  of  its 


88  rEI.VIC    INFLAMMATION. 

absence.  Infected  hematoma  following  ruptured  ectopic 
gestation,  where  the  clot  is  in  the  folds  of  the  broad 
ligament  assumes  the  characteristics  of  other  fluid  accum- 
ulations in  the  ligament.  Blood  clotted  and  free  in  the 
pelvis,  infected  and  encapsulated  by  lymph,  forces  the 
uterus  forward  and  immovably  fixes  it.  The  lateral  for- 
nices  are  symmetrically  occupied  by  the  clot.  In  some 
cases  a  positive  diagnosis  cannot  be  made  without  a 
posterior  vaginal  incision,  a  perfectly  safe  procedure. 

Treatment. — Pus  in  a  preformed  sac  (pyosalpinx)  is 
radically  cured  only  upon  extirpation  of  the  sac.  In- 
cision and  drainage  will  relieve,  but  not  insure  against  a 
relapse  at  some  distant  day.  Inasmuch  as  a  pus  tube  is 
rarely  found  upon  one  side  and  normal  adnexa  upon  the 
other,  vaginal  ablation  of  uterus  and  adnexa  is  the  indi- 
cated radical  operation  in  all  cases.  If  ablation  is  not 
accepted  the  preferable  operation  in  all  cases  of  pyosal- 
pinx purely  pelvic  in  their  relations  and  important  asso- 
ciations, is  evacuation  through  the  vagina  by  broad  in- 
cision. This  treatment  is  to  be  practiced  to  the  exclusion 
of  laparotomy  and  removal  in  all  except  a  limited  number 
of  cases.  The  excepted  cases  are  the  few  in  which 
appendicitis  coexists  with  a  pyosalpinx,  and  cases  where 
a  fistula  exists  between  the  small  gut  and  tube.  I  have 
never  seen  a  gonorrheal  pus  tube  upon  one  side,  in  which 
there  was  not  sufficient  tubal  or  ovarian  disease  upon  the 
other  to  warrant  its  removal  if  it  existed  alone.  The 
treatment  is  either  wholly  conservative  (see  Conservative 
Treatment)  or  thoroughly  radical. 

' SeqiielcB. — Very  rarely  these  pus  tubes  rupture  into 
the  general  peritoneal  cavity.  But  in  many  cases  they 
leak  slowly,  causing  the  effusion  of  large  masses  of  iso- 
lating lymph,  beneath  the  plates  of  which  the  pus  oozes 
(see  Diffuse  Pelvic  Suppuration).  Pus  tubes  form  adhe- 
sions with  the  intestines,  usually  with  the  sigmoid,  and 
may  rupture  into  it.  If  the  opening  is  into  the  sigmoid 
the  pus  is  discharged /i'r/rr/?/ wand  the  pus-sac  becomes 
additionally  infected  from  the  gut.  If  the  fistula  is  into 
a  knuckle  of  small  gut  the  pus  will  be  absorbed.     The 


SALPINGTTTS. 


89 


pus  may  also  find  its  way  into  the  vagina  or  even  into 
the  bladder.  The  fistulse  are  not  permanent,  but  open 
and  close  in  obedience  to  the  distention  of  the  pus-sac. 
Pyosalpinx  upon  the  right  side  is  very  frequently  asso- 
ciated with,  and  adherent  to,  a  diseased  appendix  vermi- 
formis.  Life  is  destroyed  by  the  prolonged  suppuration, 
and  nephritis  is  a  common  sequela.  In  questioning  over 
three  hundred  cases  of  phthisis,  I  found  that  four  in 
every  seven  never  had  any  lung  symptoms  until  the  onset 
of  an  attack  of  pelvic  inflammation.    The  general  debility 


Fig.  27. — Tuberculosis  of  the  Fallopian  tubes.     The  disease  has  extended  to 
the  peritoneum,  which  is  covered  with  tubercles  (Penrose). 

following  the  latter  conduced  to  the  inception  of  the 
-former.  Not  pelvic  inflammation  but  nephritis  and 
phthisis  end  the  lives  of  most  of  these  sufferers. 


TUBERCULAR  SALPINGITIS. 

This  is  always  chronic;  and  it  is  doubtful  if  it  arises 
primarily,  being  secondary  to  tubercular  peritoneal  dis- 
ease. I  have  seen  one  case  in  which  I  thought  it  pri- 
mary. The  disease  may  be  due  to  a  general  tuberculosis, 
to  extension  from  a  tubercular  intestinal  ulcer,  or  be  set 
up  by  tubercle  bacilli  introduced  through  the  uterus  by 


9° 


PELVIC   INFLAMMATION. 


means  of  ditty  instruments  (Fig.  27).  The  tubercles  lie 
upon  the  peritoneal  surface  of  the  tube,  as  well  as  in  the 
cavity,  forming  miliary  tubercular  salpingitis.  Or  the 
disease  may  assume  either  of  the  two  other  common' 
tubercular  types:  caseous  infiltration,  or  chronic  fibroid 
tuberculosis.  In  one  instance,  there  will  be  a  tube  filled 
with  cheesy  pus  and  studded  with  tubercles  ;  while,  in 
another,  the  tubercles  are  few,  and  the  production  of 
connective  tissue  marked.  Tubercular  disease  consti- 
tutes about  fifteen  per  cent,  of  all  inflammatory  pelvic 
disease  of  a  chronic  type. 

The  symptoms  and  sig-iis  are  those  of  pyosalpinx,  or 
other  chronic  tubal  disease,  due  to  other  causes. 

Treatment. — Whenever  upon  exploratory  vaginal  sec- 
tion tubercular  adnexal  disease  is  found,  ablation  should 
be  performed.  But  this  statement  may  be  qualified  some- 
what by  excluding  operation  when  general  peritoneal 
tuberculosis  coexists. 


PELVIC  PERITONITIS. 

The  normal  pelvic  peritoneum  is  generally  transparent, 
and  through  it  the  color  of  the  underlying  tissue  maybe 
detected.  In  certain  portions  of  the  pelvis  it  is  thicker 
than  at  other  points,  notably  over  the  rectum  and  the 
iliac  vessels,  and  at  these  points  the  peritoneum  is 
opaque.  Over  the  uterus  the  peritoneum  is  thin,  and 
the  peritoneal  covering  of  the  tubes  is  exceedingly 
delicate. 

When  inflamed  the  peritoneum  becomes  deeply  in- 
jected. Its  color  will  vary  from  a  delicate  pink  to  a 
livid  hue,  according  to  the  severity  of  the  process.  At 
first  serum  is  poured  out  in  a  variable  quantity.  As  the 
circulatory  stasis  increases  the  endothelial  cells  shrink 
away  from  each  other,  and  the  underlying  lymph  spaces 
are  exposed.  White  blood-corpuscles  and  plasma  cells  pass 
out  upon  the  surface  of  the  membrane,  where  they  form 


PELVIC   rERITONITIS. 


91 


masses  of  "  lymph."  If  the  process  subsides,  these  lymph 
masses  change  into  connective  tissue  bundles  or  "  adhe- 
sions," which  become  supplied  with  blood-vessels  and 
are  covered  with  endothelial  cells.  If  the  infecting 
agent  overwhelms  the  vital  forces,  the  cells  die  and  pro- 
duce pus.  According  to  the  nature  of  the  result  of  the 
infection,  we  have  either  a  slightly  injected  peritoneum 
with  serum  as  a  result,  or  one  deeply  colored,  smooth, 
and  shining  generally,  but  at  points  unglazed,  and  cov- 
ered by  lymph ;  or  one  livid  in  hue,  rough  in  appearance, 
and  devoid  of  endothelium,  studded  here  and  there  by 
small  lymph  masses,  and  showing  frequent  spots  of  puru- 
lent lymph.  Pus  in  the  pelvic  peritoneal  cavity  may  be 
whitish,  yellow,  or  greenish-yellow.  Usually  it  is  odor- 
less, but  it  may  be  tainted  with  intestinal  gases  without 
there  being  an  opening  into  the  gut. 

Causes. — The  causes  of  pelvic  peritonitis  may  be  classi- 
fied as  direct  and  contributing. 

Direct. — Pelvic  peritonitis  in  women  is  caused  by 
colon  bacilli,  gonococci,  staphylococci,  streptococci,  tubercle 
bacilli,  and  more  rarely  by  other  pathogenic  germs.  A 
certain  form  of  peritonitis  is  also  produced  by  the  chem- 
ical irritants  which  are  contained  in  antiseptic  dressings, 
when  these  touch  the  peritoneum.  According  to  the 
nature  of  the  infection  the  character  of  the  lesions  will 
vary.  Where  colon  bacilli  cause  the  inflammation,  there  is 
but  little  lymph  produced,  and  not  much  of  serum  ;  but 
it  is  doubtful  if  suppurative  peritonitis  is  ever  set  up  by 
the  colon  bacillus  alone.  Peritonitis  caused  by  the  colon 
bacillus  is  less  active  than  any  other,  and  the  local  dis- 
turbances are  slight.  It  is  found  most  commonly  as  a 
result  of  inflammation  of  the  colon  when  this  is  accom- 
panied by  bowel  distention  and  retention  of  feces.  Clin- 
ically, we  meet  with  it  most  often  after  it  has  produced 
adhesions,  or  in  its  acute  stage  as  a  complication  in  the 
after-treatment  of  intrapelvic  operations.  Very  slight 
toxemia  is  produced  by  it,  and  hence,  the  rise  in  tem- 
perature and  pulse  rate  may  be  so  slight  as  to  be 
unnoticed.     In  cases  of  adherent  retroposed  uteri  which 


g2  PELVIC   INFLAMMATION. 

we  meet  with  in  young  women  who  have  never  had 
uterine  or  tubal  inflammation,  the  adhesions  are  probably 
always  due  to  the  colon  bacillus.  Whenever  any  organ 
rests  immovable  upon  one  spot  of  the  large  gut  for  a 
length  of  time,  migration  of  the  colon  bacillus  is  apt  to 
result,  causing  limited  effusion  of  lymph,  and  the  ulti- 
mate formation  of  delicate  adhesions.  In  the  mistaken 
treatment  of  abdominal  diseases  by  opiates,  the  migration 
of  colon  bacilli  is  facilitated. 

Where  peritonitis  is  caused  by  g'ouococci,  scrum  and 
lymph  are  produced.  Under  ordinary  conditions  gono- 
cocci  do  not  produce  purulent  peritonitis.  Suddenly 
flooding  the  pelvic  cavity  by  a  large  quantity  of  virulent 
gonorrheal  pus  will  set  up  a  purulent  peritonitis.  Pelvic 
peritonitis  due  to  gonorrhea  may  be  caused  by  the 
gonococci  reaching  the  peritoneum  through  the  uterus 
and  Fallopian  tubes,  through  the  bladder,  or  through  a 
ureter.  By  far  the  greater  number  of  cases  of  this  form 
of  peritonitis  are  produced  by  the  infection  coming 
through  the  uterus  and  tubes.  Gonorrhea  causes  peri- 
tonitis by  extending  directly  along  the  continuity  of  the 
tissue,  and  not  through  the  medium  of  the  lymphatics. 
As  a  consequence  we  have  the  peritonitis  secondary  to  a 
salpingitis.  The  first  effusion  of  plastic  lymph  occurs  at 
the  fimbriated  end  of  the  affected  tube,  effectually  closing 
it,  and  causing  it  to  unite  to  any  adjacent  organ.  As  the 
infection  progresses,  lymph  is  thrown  out  upon  the  sur- 
face of  the  uterus  as  well  as  on  the  tube.  The  produc- 
tion of  serum  is  slight,  and  altogether  the  tendency  of 
the  peritoneal  inflammation  is  to  localization.  A  char- 
acteristic of  gonorrheal  peritonitis  is  its  tendency  to 
recurrence.  The  younger  the  subject  infected,  the  more 
pronounced  the  peritonitis.  The  puerperal  state  after 
the  third  month  appears  to  grant  a  certain  immunity 
against  this  form  of  infection.  It  is  generally  seen  in 
unimpregnated  women.  For  the  lesions  induced  in  the 
ovaries  and  tubes  by  this  infection  the  reader  is  referred 
to  "Salpingitis"  and  "Ovaritis." 

Pelvic  peritonitis  due  to  stapliylococci  usually  results  in 


PELVIC   PERITONITIS, 


93 


the  limited  production  of  both  serum  and  lymph.  I  do 
not  believe  that  primary  purulent  peritonitis  is  ever 
caused  by  staphylococci.  The  infection  may  reach  the 
peritoneum  through  either  the  medium  of  the  tubes  or 
through  the  lymphatics,  or  by  both  channels.  In  the 
former  case  the  peritoneum  at  the  fimbriated  end  of  the 
tube  is  first  affected,  resulting  in  the  closure  of  the  tube. 
Here  the  pelvic  peritonitis  is  limited.  Where  the  infec- 
tion passes  to  the  peritoneum  through  the  lymphatics, 
the  peritonitis  occurs  as  a  primary  disease.  According 
to  the  extent  of  the  infection  the  severity  of  the  periton- 
itis will  vary.  The  passage  of  an  unclean  sound  which 
bruises  a  slight  area  of  endometrium  will  cause  but  a 
limited  degree  of  infection  and  a  small  amount  of  lymph 
will  be  poured  out  upon  the  broad  ligament  or  uterine 
wall.  The  same  kind  of  infection  occurring  at  the  site 
of  a  recently  detached  placenta  may  result  in  an  infec- 
tion which  will  be  the  cause  of  a  general  plastic  pelvic 
peritonitis.  The  degree  of  the  peritonitis  will  corres- 
pond to  the  number  of  lymphatics  which  are  involved. 
If  this  infection  occurs  in  the  puerperal  state,  and  results 
in  the  production  of  a  broad  ligament  phlegmon,  this 
may  be  the  means  of  starting  a  suppurative  type  of  peri- 
tonitis. But  this  suppurative  peritonitis  will  be  second- 
ary to  a  plastic  form,  and  the  pus  will  be  locked  in. 
Diffuse  suppuration  in  the  pelvis  will  result,  but  not 
primary  purulent  peritonitis.  There  is  a  vast  difference, 
both  in  the  local  lesions  and  danger  to  life.  The  tend- 
ency of  infection  by  the  colon  bacillus  is  to  produce 
lymph-effusion  at  the  point  of  migration  of  the  bacillus, 
and  this  will  result  in  attaching  that  point  to  any  organ 
which  rests  upon  it.  Primary  tubal  and  ovarian  diseases 
are  not  produced  by  the  colon  bacillus. 

The  tendency  of  infection  by  the  gonococcus  is  to 
produce  primary  suppurative  salpingitis  with  secondary 
peritonitis  about  the  tubal  orifices.  This  focus  of  sup- 
puration in  the  tube  becomes  the  agent  by  which  other 
attacks  of  peritonitis  are  produced.  Recurrent  plastic 
peritonitis  is  characteristic  of  gonorrheal  infection.     The 


94 


PELVIC   INFLAMMATION. 


tubal   lesions  are  more  marked   than   those  of  the  peri- 
toneum. 

Staphylococcus  infection  tends  to  produce :  (a)  tubal 
inflammation  with  secondary  peritonitis  ;  and,  (d)  pelvic 
lymphangitis  with  primary  peritonitis.  The  extent  of 
the  peritonitis  is  greater  than  where  the  gonococcus  is 
the  infecting  agent. 

None  of  these  pathogenic  germs  tends  ordinarily  to 
produce  primary  purulent  peritonitis.  They  are  usually 
local  in  their  activity  and  produce  but  mild  toxemia. 

Such  is  not  the  tendency  of  the  streptococcus.  From 
its  first  introduction  into  the  system  this  germ  produces 
the  greatest  amount  of  septicemia  relative  to  the  degree 
of  the  local  disturbance.  Introduced  into  an  unimpreg- 
nated  uterus,  it  produces  either  tubal  inflammation  with 
peritonitis  secondary  to  that,  or  primary  peritonitis  by 
extension  through  the  lymphatics.  Occurring  in  the 
absence  of  a  recent  gestation  it  results  in  the  liberal  out- 
pouring of  serum  and  the  widest  effusion  of  lymph  by 
the  peritoneum.  As  a  result,  there  is  suppuration  in  the 
tube  or  ovary,  or  both,  which  is  surrounded  by  large 
masses  of  lymph.  There  is  never  intermission,  however, 
in  an  inflammation  produced  by  the  streptococcus.  It 
never  becomes  strictl)^a  local  disease,  but  there  is  a  con- 
tinuation of  acute  manifestations  with  marked  exacerba- 
tions. After  a  time  the  pus  leaks  into  the  lymph  planes 
and  the  gravest  form  of  diffuse  pelvic  suppuration  is  pro- 
duced. The  streptococcus  is  found  in  the  product's  of 
inflammation  in  such  pelves,  but  there  are  such  marked 
differences  in  the  gravity  of  the  symptoms  in  various 
cases,  that  we  are  forced  to  believe  that  there  is  a  great 
variability  in  the  virulence  of  this  germ. 

Occurring  in  a  uterus  recently  aborted  or  delivered, 
this  form  of  infection  may  result  in  primary  purulent  peri- 
tonitis. This  is  the  gravest  form  of  peritoneal  inflam- 
mation. Large  quantities  of  serum  are  produced  ;  the 
peritoneum  is  livid  in  color ;  the  effusion  of  plastic  lymph 
is  limited,  and  as  a  result,  there  is  little  or  no  tendency 
to  localization  of  the  disease.     Death  may  occur  before 


PELVIC   PERITONITIS. 


95 


any  lymph  is  effused  upon  the  pelvic  peritoneum,  there 
being  induced  a  complete  stasis  in  the  local  vital  forces. 
From  the  first  initiative  chill  to  death  may  be  less  than 
three  days. 

If,  however,  the  septicemia  is  not  so  rapidly  fatal,  the 
infection  tends  to  cause  death  of  the  cells  thrown  out  by 
the  peritoneum.  The  pelvic  peritoneum  becomes  granu- 
lar in  appearance,  and  isolated  spots  of  pus  and  lymph 
are  scattered  over  its  surface.  There  is  slight  tendency 
to  union  between  the  organs  in  contact.  The  lower  pel- 
vis is  filled  with  fluid,  sometimes  straw-colored,  with  iso- 
lated pus  cells  and  flocculi  of  lymph,  or  cream-colored 
from  admixture  of  pus.  The  fluid  has  a  putrid  odor  in 
many  cases.  The  least  touch  suffices  to  break  the  peri- 
toneum, which  is  denuded  of  its  endothelium.  The  ten- 
dency of  purulent  pelvic  peritonitis  is  to  become  purulent 
general  peritonitis.  It  is  always  fatal,  unless  checked  by 
operation,  causing  death  either  by  heart  paralysis  from 
the  effects  of  its  toxins,  or  by  producing  endocarditis, 
pneumonia  or  nephritis. 

Sometimes,  usually  in  cases  not  aborted,  or  in  those 
aborted  before  the  third  month,  the  peritoneum  will  be 
able  to  resist  the  streptococci  sufficiently  to  produce  large 
masses  of  vitalized  lymph.  If  it  does  this,  the  pus  which 
the  infection  has  produced  in  the  broad  ligament  or  tube 
or  ovary  will  be  locked  in.  If  this  localization  of  the 
suppuration  is  once  obtained,  the  peritoneum  throws  out 
enormous  masses  of  lymph.  The  intestines,  omentum, 
bladder  and  fundus  uteri  become  firmly  united  at  the 
pelvic  brim,  and  the  pelvic  suppuration  is  effectively 
locked  in. 

Streptococcus  infection,  if  not  fatal  in  a  few  days, 
always  results  in  suppuration  somewhere.  Occurring  in 
the  unimpregnated  uterus,  the  pus  may  be  produced  in 
tube,  ovary  or  broad  ligament,  with  diffuse  plastic  peri- 
tonitis as  a  complication.  Occurring  free  in  the  pelvic 
cavity,  the  pus  is  located  according  to  the  posture  of  the 
patient,  as  any  other  fluid  would  be. 

Contributing   Causes. — Although   we   find  that   all 


gO  PELVIC   INFLAMMATION. 

forms  of  pelvic  peritonitis  are  due  to  some  irritant,  either  of 
a  germ  or  chemical  nature,  these  direct  causes  are  not 
alvva3^s  operative  unless  there  exist  local  conditions  which 
are  propitious  to  their  activity.  The  peritonitis  due  to 
gonorrhea  we  find  more  often  occurring  at  the  ■})ie}istnial 
periods.  At  this  time  tlie  physiological  exfoliation  of  the 
epithelium  of  the  endometrium  conduces  to  the  introduc- 
tion of  the  gonococcus  into  the  pelvis.  Furthermore, 
gonorrhea  may  for  years  remain  latent  in  the  cervical 
canal,  and  a  general  gonorrheal  infection  of  the  pelvis  be 
set  up  by  operations  upon  a  uterus  so  infected.  We  may 
consider  trauma  as  a  contributing  cause.  Any  injury  to 
the  general  system  which  will  produce  marked  stasis  in 
the  pelvic  circulation  will  also  suffice  to  bring  on  an 
attack  of  peritonitis  where  latent  pathogenic  cocci  are 
present.  Such  an  agency  may  be  prolonged  exposure  to 
cold,  and  great  physical  effort.  Those  germs  which  are 
common  in  the  bowel  operate  as  causes  of  peritonitis  when 
the  bowels  are  inactive  and  feces  are  retained.  Chronic 
constipation  undoubtedly  conduces  to  peritonitis  of  one 
form.  The  breaches  of  surface  incident  to  abortion  and 
labor  are  particularly  conducive  to  the  onset  of  an  attack 
of  peritonitis,  by  furnishing  points  for  the  entrance  of 
germs  into  the  system. 

Syinptonis. — As  pelvic  peritonitis  produces  three  kinds 
of  effusion,  serum,  lymph,  (resulting  in  adhesions  recent 
or  old),  and  pus,  the  local  signs  will  vary  greatly.  The 
degree  of  toxemia  will  be  largely  governed  by  the  nature 
of  the  infecting  agent,  and  there  is  a  wide  range  in  symp- 
toms. The  peritonitis  which  accompanies  gonorrheal  and 
septic  infections  is  so  commonly  associated  with  or 
caused  by  tubal  diseases  that  the  reader  is  referred  to 
the  chapter  on  "  Salpingitis  "  for  its  description. 

There  is  undoubtedly  a  period  of  incubation  from  the 
introduction  of  pathogenic  germs  to  the  first  evidence  of 
peritonitis.  Just  how  long  this  is  we  do  not  know,  but 
I  have  thought  that  where  the  infection  travels  through 
the  tubes  it  more  rapidly  produces  peritonitis  than  where 
the  lymphatics  are  the  carriers.     To  this,  however,  I 


PELVIC   PERITONITIS. 


9  7 


must  make  the  exception  that  in  infection  occurring  after 
the  third  month  of  gestation  the  peritonitis  usually  occurs 
directly  as  a  result  of  the  lymphatic  infection,  and  not 
through  the  medium  of  the  tubes.  In  any  case,  from 
two  to  three  days  elapse  from  the  time  the  germ  of  in- 
flammation is  introduced  into  the  uterus  to  the  first  evi- 
dence of  peritonitis ;  and  a  few  hours  only  are  needed 
for  the  peritoneum  to  develop  some  evidence  of  inflam- 
mation after  being  brought  into  contact  with  germs. 

There  is  usually  at  first  a  free  effusion  of  serum.  This 
I  have  never  been  able  to  determine  upon  examination, 
and  have  found  it  only  after  the  peritoneum  has  been 
severed. 

When  lymph  is  first  thrown  out  it  is  colorless.  Within 
a  few  hours  vessels  appear  in  it,  and  it  becomes  organized 
into  a  new  tissue.  Lymph  tends  to  hold  immobile  the 
organs  between  which  it  lies.  As  a  consequence  we  have 
fixity.  If  the  lymph  be  exuded  upon  the  broad  ligaments 
only,  these  are  thereby  stiffened,  and  bilateral  mobility  of 
the  uterus  becomes  limited.  Furthermore,  the  thickened 
broad  ligaments  have  lost  their  elasticity,  and  the  exam- 
ming  finger  finds  a  density  in  each  lateral  vaginal  fornix, 
where  formerly  there  was  perfect  elasticity.  The  uterus 
is  fixed,  and  at  the  sides  of  the  cervix  are  dense  masses 
of  exudate.  In  extreme  cases  of  plastic  effusion  the 
uterus  will  be  as  immovable  as  though  resting  in  the 
knot-hole  of  a  board,  and  the  density,  inelasticity  and  in- 
filtration will  be  all  around  the  uterus.  If  the  lymph  be 
effused  upon  one  broad  ligament  only,  the  cervix  can  not 
be  moved  away  from  the  affected  side,  and  in  drawing 
down  the  uterus  the  cervix  will  swing  toward  the  firmer 
ligament, — it  will  not  come  down  in  the  middle  line  of 
the  vagina.  Masses  of  recent  lymph  are  soft,  but  do  not 
give  out  fluctuation.  The  sense  of  a  mass  is  produced 
as  much  by  the  edema  of  the  tissues  as  by  the  lymph. 
Where  the  lymph  has  been  effused  about  a  tumor  or  pus 
focus,  it  increases  the  bulk  of  the  mass  and  fixes  it.  And 
when  the  outpouring  of  lymph  has  been  repeated,  the 
density  of  fluid  accumulations  is  increased,  leading  to 
7 


98 


PELVIC   INFLAMMATION. 


their  being  mistaken  for  solid  tumors.  The  effect  of 
thick  lymph  accumulations  upon  involved  organs  is  of 
interest.  If  the  effusion  has  taken  place  about  a  bladder 
which  has  been  neglected  in  over  distention,  that  organ 
will  be  fixed  high  up  and  cannot  be  completely  emptied 
And  if  distention  of  the  bladder  is  prevented  by  ofc- 
repeated  catheterization  while  the  lymph  is  being  poured 
out,  the  bladder  will  be  fixed  in  systole,  and  distention 
will  be  impossible  so  long  as  the  adhesions  remain.  As 
I  have  pointed  out,  lymph  tends  to  fixation  of  the  uterus. 
The  same  is  true  of  the  ovaries  and  tubes  where  they  are 
implicated  in  the  effusion  ;  they  remain  attached  to  what- 
ever organs  they  may  rest  against  at  the  time  the  lymph 
was  effused  about  them,  and  can  move  only  as  those  or- 
gans move.  Where  the  lymph  is  secreted  about  a  rectum 
distended  by  feces  or  gas,  the  gut  remains  canalized.  As 
a  consequence  we  have  a  distended  rectum,  one  whose 
walls  are  never  collapsed,  a  common  feature  of  diffuse 
pelvic  peritonitis.  If  the  rectum  be  empty  when  large 
masses  of  lymph  are  produced  about  it,  it  will  be  partially 
strictured.  The  ureters  pass  beneath  both  broad  liga- 
ments under  the  peritoneum.  Recent  effusion  of  lymph 
has  little  effect  upon  them.  If  a  knuckle  of  small  gut  is 
caught  and  fastened  by  lymph  in  the  pelvis,  its  function 
is  markedly  interfered  with,  chiefly  in  the  matter  of  rhyth- 
mical peristalsis.  The  adhesions  which  result  from  lymph, 
while  much  less  than  would  be  expected  to  follow  so 
generous  a  production  of  this  material,  yet  produce  grave 
consequences.  The  bladder  may  be  held  at  the  fundus 
uteri,  permanently  distended.  The  retroverted  uterus 
may  be  fixed  to  the  rectum  and  be  capable  of  replacement 
only  by  ballooning  out  the  rectum.  The  contraction  of 
the  lymph  upon  the  broad  ligament  causes  stricture  of 
the  ureter  and  hydro-ureter.  The  tubes  are  distorted 
and  strictured,  the  pelvic  vessels  obstructed,  and  a  con- 
dition of  atrophy  in  the  genital  organs  results  from  im- 
peded circulation.  The  adhesions  to  the  small  intestines 
are  continuously  pulled  against.  As  a  result,  they  are 
teazed  out  so  as  to  be  many  inches  in  length,  forming 


PELVIC   PERITONITIS. 


99 


bridges  across  which  loops  of  intestine  may  fall  and  be- 
come strangulated.  Adhesions  between  the  adnexa  and 
the  peritoneum  over  the  psoas  muscles  may  be  so  stout 
as  seriously  to  impede  bodily  movements.  An  interest- 
ing tendency  of  these  false  unions  is  that  their  vessels 
furnish  additional  nourishment  to  the  attached  organs. 
An  ovary  may  become  detached  from  its  normal  site  and 
be  entirely  supported  through  false  bands.  The  appen- 
dix vermiformis  may  receive  its  sole  blood  supply  through 
a  new  attachment  to  the  right  appendages,  and  slough 
off  when  these  are  severed.  Neoplasms  have  been  found 
separated  from  the  uterus  and  nourished  through  adhe- 
sions. The  spleen,  if  attached  in  this  way,  becomes  en- 
larged. Omental  adhesions  often  produce  at  the  seat  of 
attachment  large  masses  of  fat  tumor  through  the  influ- 
ence of  the  vessels  running  through  the  new  bands. 

Where  intraperitoneal  pus  is  the  result  of  peritonitis, 
the  pelvic  organs  are  all  fixed,  partly  by  lymph  and  partly 
by  subserous  edema.  There  is  marked  lack  of  elasticity 
in  the  vaginal  vault.  If  the  pus  be  very  fluid  it  cannot 
be  detected,  but  when  thick  a  spongy  bulging  may  be  felt 
in  the  posterior  vaginal  fornix.  This  changes  with 
change  in  the  posture  of  the  patient,  and,  unlike  very  re- 
cent lymph,  can  be  displaced  upward  by  pressure.  Sen- 
sitiveness to  pressure  is  slight  when  serum  alone  is  pro- 
duced; where  lymph  is  effused  it  is  marked  ;  and  in  pri- 
mary suppurative  peritonitis  the  lack  of  pelvic  sensitive- 
ness and  pain  is  a  marked  feature.  In  fact,  in  the  worst 
cases  of  purulent  peritonitis  there  is  pelvic  analgesia. 
This  is  an  important  sign. 

Tympanites. — This  is  noticeable  in  cases  of  purulent 
and  lymph  effusion,  but  is  not  present  in  serous  effusion. 
It  is  dependent  upon  the  degree  and  kind  of  infection, 
the  state  of  the  bowels,  and  the  medication.  If  the 
bowels  are  kept  empty  by  washings  and  no  opiates 
given,  the  tympanites  is  not  marked  in  pelvic  peritonitis. 

Subjective  Symptoms. — Pain  is  slight  where  serum 
alone  is  produced  and  when  the  infection  is  followed  by 
very  gradual  effusion  of  lymph.     When   intraperitoneal 


lOo  PELVIC   INFLAMMATION. 

pus  (purulent  peritonitis)  is  present,  pain  is  not  marked 
and  may  be  entirely  absent.  Where  a  sudden  sharp  out- 
pouring of  lymph  takes  place,  the  pain  is  severe  and 
continuous.  It  is  exceedingly  difficult  to  say  how  much 
pain  is  the  result  of  the  involvement  of  the  peritoneum, 
and  how  much  is  caused  by  coincident  inflammation  of 
uterus,  ovaries  or  tubes.  Movement  of  the  organs  over 
which  lymph  is  effused  increases  the  pain.  Sudden 
pelvic  pain,  accompanied  by  grave  general  symptoms, 
pyrexia,  and  septicemia,  and  followed  by  a  rather  abrupt 
cessation  of  the  pain,  points  to  purulent  peritonitis. 

Temperature. — Where  serum  alone  is  produced,  the 
temperature  is  seldom  elevated  one  degree.  (I  consider 
99f  °  as  normal  rectal  temperature.)  The  height  of  the 
fever  accompanying  lymph  effusion  will  vary  with  the 
patient's  general  condition,  the  kind  of  infection  present, 
and  the  degree  of  the  infection.  Gonorrheal  peritonitis 
rarely  produces  a  temperature  above  I02j^°.  The 
same  is  true  with  staphylococcus  infection.  In  strepto- 
coccus poisoning  the  temperature  rapidly  reaches  103°, 
and  is  more  often  above  than  below  that  point.  The 
evening  temperature  is  generally  a  degree  above  the 
morning.  A  temperature  holding  steadily  for  more 
than  a  day  above  103°  should  create  great  uneasiness  in 
the  medical  attendant.  This  is  particularly  necessary 
when  the  fever  comes  on  after  operation,  abortion,  or 
labor.  There  are  marked  fluctuations  in  the  tempera- 
ture in  most  cases.  The  falls  in  temperature  will  be 
found  to  correspond  pretty  accurately  with  an  increased 
excretion  of  urine  and  evacuation  of  the  bowels. 
Through  the  kidneys  and  the  bowels  toxins  are  elimi- 
nated. 

The  pulse  in  gonorrheal  peritonitis  seldom  reaches 
1 10°.  Where  the  infecting  agent  is  the  streptococcus, 
the  pulse  rarely  falls  below  110°  beats  a  minute.  Ot 
more  value  in  determining  the  nature  of  the  infecting 
agent  than  either  pulse  or  temperature  alone,  are  their 
relative  marks.  Thus,  a  temperature  of  103°  with  a 
pulse  less  than  110°  need  cause  little  apprehension  as  to 


PELVIC   PERITONITIS.  loi 

the  ultimate  result,  while  the  same  temperature  with  a 
pulse  of  130°  calls  for  immediate  interference,  and  is 
indicative  of  a  virulent  infection,  probably  streptococcic. 
The  effusion  of  lymph  does  not  cause  the  rapid  pulse 
and  fever.  Great  masses  of  lymph  may  be  thrown  out 
about  a  gauze  drain  in  the  pelvis,  and  yet  the  pulse  be 
but  slightly  accelerated  and  fever  be  absent.  The  fever 
and  quick  pulse  accompanying  those  degrees  of  infec- 
tion which  result  in  lymph  effusion  are  produced,  not  by 
the  lymph,  but  by  the  toxins  of  the  invading  germs. 
We  find  slight  rise  in  temperature  attending  the  produc- 
tion of  large  plaques  of  lymph,  and  high  temperature 
where  no  lymph  is  produced.  The  fever  is  due  to  the 
toxemia,  not  to  the  outpouring  of  lymph 

Rigors. — Chills  are  not  features  of  peritonitis,  except 
when  there  is  a  sudden  rise  in  temperature  from  a  point 
near  101°  to  one  4°  or  5°  higher.  Then  a  slight 
rigor  will  mark  the  inception  of  the  rise  in  many  cases. 
Rigors  may  be  stated  to  be  features  rather  of  a  general 
septicemia  than  of  a  localized  peritonitis. 

Digestive  Symptoms. — There  being  an  overproduction 
of  bile,  vomiting  is  apt  to  follow  overloading  the  stomach 
in  cases  of  pelvic  peritonitis.  Beyond  this,  vomiting  is 
rarely  present  as  a  symptom  of  pelvic  peritonitis.  The  onset 
of  persistent  vomiting,  where  not  produced  by  improper 
food  and  drugs,  if  accompanied  by  high  pulse  and  tem- 
perature, is  alarming.  It  is  indicative  of  a  peritonitis 
which  is  extending  above  the  pelvic  brim.  The  bowels 
are  prone  to  costiveness  in  pelvic  peritonitis,  on  account 
of  interference  with  their  peristalsis  by  adhesions,  and  in 
part  to  the  increase  in  pain  produced  by  defecation.  In 
purulent  peritonitis  there  is,  on  the  contrary,  very  com- 
monly a  diarrhea. 

The  kidneys  are  rarely  affected  in  any  forms  of  infection 
save  one.  The  urine  is  increased  in  amount  and  the  per- 
centage of  urea  is  increased.  In  streptococcus  infection 
acute  parenchymatous  nephritis  is  a  common  compli- 
cation. 

The  heart  and  the  lungs  are  not  affected  in  any  form  of 


T02  PELVIC   INFLAMMATION. 

peritonitis,  except  that  due  to  streptococcus,  the  purulent 
form.  Endocarditis,  pneumonitis,  and  pleuritis  are  very 
often  met  with  in  cases  of  purulent  peritonitis.  It  is  rare 
for  a  case  of  streptococcus  infection  to  recover  without 
some  grave  complication. 

Diag-uosis. — The  diagnosis  of  pelvic  peritonitis  is 
generally  embraced  in  that  of  some  one  of  its  accom- 
panying lesions,  salpingitis  endometritis,  etc.  It  is  not 
so  difficult  to  detect  an  effusion  of  lymph  in  the  pelvis. 
I  have  never  been  able  to  determine  the  presence  of  the 
serum  which  I  have  evacuated  so  many  times.  The  im- 
portant and  difficult  task  is  to  diagnosticate  the  presence 
of  primary  purulent  pelvic  peritonitis.  I  may  mention 
the  more  usual  features  of  this  disease:  usually  a  history 
of  criminal  abortion  or  instrumental  labor,  often  an  initia- 
tive chill,  pulse  from  the  first  iio°  or  more,  temperature 
at  or  above  103°,  tympanites,  not  much  pain,  stupid  face, 
tendency  to  somnolence,  sordes  on  teeth,  red  furred 
tongue,  muttering  delirium ;  uterus  fixed  in  pelvis,  vagi- 
nal vault  hardened,  spongy  mass  in  posterior  cul-de-sac, 
not  much  sensitiveness.  The  woman  looks  very  ill  in  a 
a  day.  It  is  especially  difficult  to  differentiate  suppura- 
tive pelvic  peritonitis  from  general  suppurative  periton- 
itis. I  have  never  found  a  case  of  suppurative  pelvic 
peritonitis  in  which  there  was  not  a  history  of  either 
abortion,  labor  or  trauma.  In  general  suppurative  peri- 
tonitis there  is  no  such  history;  it  is  usually  due  to 
appendicitis.  It  is  impossible  to  determine  just  when  a 
suppurative  peritonitis  arising  in  the  pelvis  ceases  to  be 
pelvic  and  becomes  general. 

Prog-nosis. — Where  the  effusion  is  purely  of  serum 
and  lymph  there  is  no  risk  to  life.  All  cases  of  purulent 
peritonitis  die  unless  operated  upon,  and  most  of  these 
perish.  In  early  surgical  interference  lies  the  only  hope 
of  saving  the  lives  of  these  women. 

If  lymph  effusions  are  allowed  to  remain  they  produce 
permanent  lesions. 

When  a  woman  has  once  had  pelvic  peritonitis  with 
the  production  of  lymph  she  has  before  her  all  her  life 


pp:lvic  peritonitis. 


103 


the  possibility  of  an  operation  of  some  sort.  The  prog- 
nosis of  peritonitis  is  markedly  influenced  by  the  nature 
of  the  causative  lesion,  whether  gonorrheal  endometritis, 
salpingitis,  pelvic  lymphangitis,  etc.  These  are  discussed 
elsewhere. 

Treatment. — If  an  effusion  of  serum  alone  is  sus- 
pected the  treatment  consists  in  preventing  further 
extension  of  the  process  by  removing  the  causative 
focus  of  infection.  The  serum  will  then  be  absorbed. 
If  lymph  is  effused,  the  cul-de-sac  should  be  opened, 
and  all  attachments  between  the  viscera  should  be 
severed,  after  the  focus  of  infection  (usually  the  uterus) 
has  been  cleansed.  (See  Exploratory  Vaginal  Section). 
This  is  necessary  because  the  lymph  in  contracting  into 
bands  produces  such  distortion  of  the  viscera  as  will 
destroy  their  function,  partially  at  least.  It  is  to  prevent 
tubal  and  ovarian  suppuration,  as  well  as  future  adhe- 
sions, that  this  operation  is  recommended.  (See  Salpin- 
gitis.) 

Suppurative  pelvic  peritonitis  demands  the  most 
energetic  measures.  The  operation  to  be  applied  is 
purely  an  evacuative  one.  In  most  cases  it  will  suffice 
to  open  the  posterior  cul-de-sac,  let  out  the  pus  and  fill 
the  pelvis  with  iodoform  gauze.  But  in  all  cases  of 
purulent  peritonitis,  the  Mikulicz  dressing  of  iodoform 
gauze  is  absolutely  necessary  to  remove  the  large  quan- 
tities of  septic  fluid  which  escape  after  the  operation,  and 
to  furnish  iodine  in  the  form  of  iodoform  in  order  that 
the  streptococci  may  be  destroyed.  The  author  has 
shown  that  this  result  follows  the  use  of  a  certain  form 
of  gauze  in  these  cases. 

I  have  had  no  experience  with  the  use  of  antistrepto- 
coccus  serum  in  these  cases,  and  cannot  see  how  it 
can  benefit  them  before  an  operation.  Given  after  an 
operation  it  may  prevent  those  complications  which 
commonly  cause  death.  Certainly,  preliminary  reports 
warrant  its  trial,  but  not  to  the  exclusion  of  measures 
here  recommended. 

General   Treatment. — When   a   heart  stimulant   is 


I04 


PELVIC   Ix\FLAMMATION. 


needed  in  pelvic  peritonitis  I  emplo}'  strychnin.  As  a 
rule  this  will  be  found  necessary  in  the  purulent  type 
only.  Here  large  doses  must  be  administered,  begin- 
ning with  gr.  Jjj  q.  4.  h.  hypodermically  and  gradually 
increasing.  I  dislike  to  give  alcohol  except  in  the  form 
of  champagne.  If  strong  liquors  are  given,  brandy  in 
six  parts  of  iced  water  is  best.  Of  brandy  5ss.  q.  3.  h.  is 
an  average  dose.  Again  this  is  needed  in  the  purulent 
type  only.  For  local  pain,  blood-letting  from  the  cervix 
and  ichthyol  tampons  10  per  cent,  furnish  greatest  relief. 
The  colon  should  be  washed  out  daily  with  a  quart  of 
normal  salt-solution.  In  most  cases  I  allow  half  diet;  but 
in  the  purulent  type  I  employ  an  exclusive  liquid  diet — 
one  ounce  of  beef  juice  every  four  hours  and  two  ounces 
of  chicken  broth  every  four  hours.  These  are  made  to 
alternate,  at  two-hour  intervals.  Between  feedings  an 
abundance  of  water,  with  a  few  drops  of  lemon  juice  to 
acidulate  it,  is  given  if  vomiting  is  present. 

The  general  treatment  of  pelvic  peritonitis  should  be 
sustaining.  Inasmuch  as  the  effusion  of  lymph  serves  a 
good  purpose  at  first,  it  is  to  be  interfered  with  o\\\y  after 
the  causative  focus  of  infection  is  cleansed.  Then,  for 
evident  reasons,  the  effusion  of  lymph  must  be  checked. 
If  pus  is  present,  it  must  be  evacuated  so  soon  as 
discovered. 


TUBERCULAR  PELVIC  PERITONITIS. 

I  have  reserved  a  description  of  tubercular  pelvic  peri- 
tonitis for  a  separate  section,  since  its  lesions  differ  in 
character  from  those  produced  by  pathogenic  cocci. 
The  bacilli  reach  the  peritoneum  through  either  the 
blood  or  the  lymphatics.  It  is  of  interest  that  tubercular 
peritonitis  is  not  a  result  of  a  similar  process  in  the 
uterus,  but  that  the  peritonitis  produced  through  the 
blood  is  merely  part  of  a  general  tuberculosis,  and   that 


TUBERCULAR   PELVIC   PERITONITIS. 


105 


which  extends  through  the  lymphatics  is  from  some 
tuberculous  focus  in  the  abdomen.  The  origin  of  cer- 
tain cases,  however,  is  obscure. 

When  the  tubercles  appear  beneath  the  peritoneum, 
they  are  in  the  form  of  gray  nodules.  The  peritoneum 
is  at  first  unchanged.  Soon  serum  is  effused'.  The  peri- 
toneum becomes  congested,  and  the  endothelium  be- 
comes multiplied  and  exfoliates.  Leukocytes  escape 
from  the  vessels,  and  blood  may  tinge  the  serous  fluid. 
The  process  may  stop  here,  and  recovery  may  take  place. 
Or,  lymph  may  result  from  the  presence  of  the  tubercles 
and  intervisceral  adhesions  result.  The  tubal  orifices 
may  close,  and  retention  cysts  be  formed.  The  tubercles 
tend  to  invade  the  tubes  and  produce  tubercular  salpin- 
gitis. Where  suppuration  results  the  pus-producing 
agent  is  not  the  tubercle  bacillus,  but  some  complicating 
pyogenic  coccus. 

The  syniptoiiis  are  those  of  pelvic  peritonitis  due  to 
other  causes  that  produce  serum  and  lymph.  Neither  by 
symptoms  nor  examination  can  the  disease  be  differen- 
tiated from  other  forms.  It  may  be  suspected  when 
peritonitis  occurs  slowly,  without  marked  acute  symp- 
toms, without  evidences  of  primary  uterine  and  tubal 
disease,  and  when  great  emaciation  and  debility  appear 
without  assignable  cause. 

The  treatment  is  always  to  be  evacuative.  The 
uterus  need  not  be  curetted.  The  cul-de-sac  is  opened 
and  all  adhesions  severed.  After  this  the  pelvis  is  irri- 
gated with  normal  salt-solution  and  a  high  Mikulicz 
dressing  is  applied.  The  strips  of  gauze  should  extend 
quite  to  the  fundus.  If  secondary  tubal  and  ovarian  dis- 
ease are  present,  vaginal  ablation  is  indicated.  The 
exposure  to  air,  the  trauma  incident  to  the  operation, 
and  the  iodine  in  the  gauze  probably  effect  the  cure. 

Serous  pelvic  peritonitis  is  innocent;  plastic  lymph- 
producing  peritonitis  is  beneficent,  but  purulent  periton- 
itis is  the  most  fatal  of  all  diseases  affecting  the  human 
body. 

Peritonitis  is  not   to  be  considered  in  the  light  of  the 


To6  PELVIC   INFT>AMMATTON. 

results  of  the  process,  but   rather  in  a  knowledge  of  its 
causes. 

The  greater  the  lymph  effusion  the  less  immediate 
danger  to  the  patient,  for  the  lymph  tends  to  lock  in  the 
infection  and  limit  it,  and  in  that  sense  it  is  beneficent. 
But  in  so  considering  it  we  must  not  be  consoled  into  an 
ignorance  of  the  ultimate  results  of  a  generous  outpour- 
ing of  lymph;  and  it  is  our  duty  to  check  it  while  check- 
ine  the  infection. 


INFLAMMATORY  DISEASES  OF  THE  OVARIES. 

Acute  Peri-ovaritis. — The  infection  may  extend  to  the 
peritoneal  covering  of  the  ovary  from  the  tube;  or  the 
ovarian  peritoneum  may  become  inflamed  conjointly  with 
the  adjacent  pelvic  peritoneum  from  an  infection  which 
has  reached  it  through  the  lymph  streams.  In  other 
words,  pelvic  peritonitis  from  any  cause  may  implicate 
the  peritoneum  of  the  ovary.  The  type  of  inflammation 
is  the  same  here  as  in  other  portions  of  the  pelvic  perito- 
neum. There  is  an  effusion  of  lymph  which  causes  the 
ovary  to  become  attached  to  adjacent  organs,  most  com- 
monly to  the  tube  and  to  the  broad  ligament.  The  en- 
tire ovary  enlarges  and  appears  edematous.  Upon  its 
surface  flakes  of  lymph  are  seen,  or  the  entire  organ  may 
be  covered  by  a  thick  plastic  deposit.  If  the  process 
subsides,  there  result  delicate  false  bands  attaching  the 
ovary  to  some  portion  of  the  pelvic  contents,  or  the 
union  may  be  so  broad  that  the  ovary  is  firmly  plastered 
to  the  uterus,  broad  ligament,  tube,  or  lateral  pelvic  wall. 
United  in  this  way,  and  repeated  attacks  of  peritonitis 
occurring,  the  ovary  may  be  entirely  isolated  from  the 
general  pelvic  cavity  and  lie  in  a  pocket  formed  by  sheets 
of  new  membrane.  In  all  cases  the  capsule  of  the  ovary 
is  thickened.  Periovaritis  may  extend  to  the  stroma  of 
the  ovary  and  to  the  follicles.  The  stroma  may  become 
infiltrated  with  new  connective  tissue  elements  and  on  con- 


INFLAMMATORY  DISEASES  OF  THE  OVARIES. 


T07 


trading  produce  "  ovarian  sclerosis  "  (see  Fig.  21).  If  the 
follicles  are  involved,  they  become  enlarged  and,  unable  to 
discharge  their  contents  through  the  thickened  capsule, 
they  present  the  characteristics  of  permanent  cysts.  The 
ovary  is  "  cystic  "  and  enlarged.  Between  the  cysts  are 
found  areas  of  sclerosed  tissue  (Fig.  28).  The  cysts  project 
beneath  the  capsule  and  appear  as  pearl-like  bodies.  Upon 
evacuating  one  a  thin  serous  or  tenacious  glairy  fluid  es- 
capes, and  the  cyst  wall  collapses.     The  cysts  maycom- 


FlG.  28. — Salpingitis  with  partial  inversion  of  the  fimbriae, 
degeneration  of  the  ovary  (Penrose). 


Cystic 


municate  with  each  other  and  large  cavities  be  thus  formed. 
Cysticdegeneration  must  not  be  confounded  with  ovarian 
cystoma  (ovarian  cyst).  They  are  essentially  different. 
Ovules  are  found  in  the  cysts  of  cystic  ovaritis  and  women 
with  such  ovaries  conceive.  We  may  therefore  consider 
this  lesion  unimportant,  and  inasmuch  as  the  organs  so 
affected  functionate  they  should  be  preserved.  Blood 
may  be  extravasated  into  one  or  more  of  the  cysts,  con- 
stituting "  ovarian  apoplexy."  The  walls  of  the  blood 
cavity  are  lined  by  a  membrane,  sometimes  dark,  in  other 
cases  yellow,  which  is  loosely  attached  to  the  surround- 
ing ovarian  stroma.     There  may  be  but  one  such  blood 


,io8 


PELVIC   INFLAMMATION. 


cyst,  often  several   inches  in  diameter,  or  there  may  be  a 
number  of  small  ones. 

The  lymphatics  of  the  ovary  may  be  chiefly  affected 
and  the  ovary  become  soft,  edematous  and  much  enlarged, 
even  four  times  its  normal  size.  Upon  splitting  such  an 
ovary  it  appears  gelatinous.  This  is  "edematous  ova- 
ritis "  (Fig.  29).  The  kind  of  infection  brought  to  the 
ovary  by  the  lymph  streams  may  be  so  virulent  that  sup- 
puration takes  place  in  the  stroma-,  or  an  acutely  inflamed 


#:^'fe^; 


Miii^flMiliBiiiiii 


Fig.  29. — Bilateral  pyosalpinx,  left  edematous  ovaritis,  and  subserous  cyst 
Vaginal  ablation. 

tube  may  become  sealed  to  the  ovary  and  the  ovary  sup- 
purate from  proximity  to  the  pus  tube.  "  Ovarian  ab- 
scess "  results  (Fig.  30).  These  pus  ovaries  are  always 
enlarged.  Sometimes  there  are  a  great  number  of  small 
foci  of  pus ;  in  other  instances  the  ovarian  capsule  sur- 
rounds one  large  pus  cavity,  I  have  removed  by  the 
vagina  one  which  lifted  the  uterus  up  out  of  the  pelvis 
and  completely  filled  the  latter. 

Surgically  the  inflammatory  states  of  the  ovary  may 
be  divided  into  non-purulent  and  purulent.  If  pus  is  not 
present,  attempts  should  always  be  made  to  save  at  least 
portions  of  the  organ.  Sclerosis  of  the  ovaries  may  co- 
exist with  a  like  process  in  the  tubes  and  the  uterus. 
Manifestly  it  is  useless  to  preserve  the  diseased  ovaries 


INFLAMMATORY  DISEASES  OF  THE  OVARIES. 


109 


when  there  exists  an  indication  for  removing  the  uterus 
and  tubes  in  such  a  case. 

Symptoms. — It  is  the  author's  behef  that  non-purulent 
inflammatory  disease  of  the  ovaries  produces  few  symp- 


FlG.  30.- 


-Very  large  ovarian  abscess,  and  half  the  uterus.    Vaginal 
ablation. 


toms.  It  is  not  the  cystic  or  apoplectic  ovary  which 
causes  the  distress,  but  the  co-existing  tubal  and  perito- 
neal disease  that  is  commonly  found  in  these  cases.  Such 
being  my  view,  I  am  disposed  to  apply  conservative  treat- 
ment to  cystic  and  apoplectic  ovaries. 

In  the  young  girl  the  ovary  is  pink  and  has  a  delicate 
capsule.     After   hundreds   of  ova   have  torn  their  way 


no  PELVIC   INFLAMMATION. 

through  the  capsule,  it  becomes  scarred  and  pale;  the 
capsule  is  thickened,  and  the  ovary  distorted.  No  two 
ovaries  are  exactly  alike;  some  are  round,  some  long, 
some  of  hourglass  shape;  some  measure  a  half  inch  in 
length,  others  as  much  as  two  inches.  In  other  words, 
there  is  the  greatest  variety  among  perfectly  normal 
ovaries.  ]3ut  surgeons  have  spayed  thousands  of  women 
because  their  ovaries  did  not  conform  to  some  ideal 
organ,  and  many  of  these  women  have  been  sent  to  the 
mad-house.  Hystero-epilepsy,  epilepsy,  neuroses  of  all 
sorts,  chronic  pelvic  pain,  in  short  almost  every  obscure 
complaint  in  women,  has  been  treated  by  the  removal  of 
ovaries  that  were  cystic,  apoplectic,  or  "atrophied."  I 
believe  that  non-purulent  ovaries  produce  few  symptoms 
other  than  a  sense  of  weight  when  they  are  large.  When 
adherent  in  the  cul-de-sac  and  compressed  by  other 
organs,  they  give  pain;  but  it  is  the  lack  of  freedom  in 
mobility  and  position,  rather  than  essential  disease,  which 
is  to  blame. 

Periovaritis  gives  no  distinguishing  symptoms,  inas- 
much as  it  is  always  accompanied  by  some  more  impor- 
tant lesion,  as  salpingitis  or  pelvic  peritonitis. 

Ovarian  Abscess  can  not  be  differentiated  from  pyosal- 
pinx.  The  history  will  sometimes  presumptively  indi- 
cate the  character  of  the  abscess.  Ovarian  abscess  is 
usually  due  to  infection  after  abortion  or  labor,  and  when 
due  to  gonorrhea,  it  is  found  as  a  lesion  secondary  to 
salpingitis  (Fig.  31).  The  symptoms  are  the  same  as  those 
of  pyosalpinx.  Upon  examining  a  pus-ovary  case  we  do 
not  get  fluctuation.  A  firmly  adherent,  dense,  sensitive 
mass  is  found  to  one  side  or  behind  the  uterus.  There 
are  evidences  of  acute  pelvic  peritonitis,  fever,  pain,  etc., 
just  as  are  found  with  pyosalpinx.  Still  I  have  seen  a 
case  of  an  enormous  pus-ovary  holding  a  pint  in  which 
there  was  absolutely  no  evidence  of  fever. 

Treatment. — Acute  Periovaritis. —  Inasmuch  as  this 
condition  is  not  found  existing  alone,  but  as  a  concomi- 
tant of  inflammation  of  other  portions  of  the  pelvic  peri- 
toneum, there  is  no  special  treatment  to  be  directed  to  it. 


INFLAMMATORY  DISEASES  OF  THE  OVARIES.      m 

Blisters  and  iodin  applied  to  the  abdomen  over  the 
ovaries  are  classical,  but  are  of  doubtful  efficacy.  I  have 
found  that  the  maintenance  of  a  definite  warmth  over  the 
abdomen  by  employing  moist  dressings  which  are  cov- 
ered by  rubber  tissue,  painting  the  vault  of  the  vagina 
with  10  per  cent,  to  20  per  cent,  ichthyol  in  boroglycer- 
ide,  and  keeping  the  bowels  washed  out  so  that  hard 
fecal  masses  do  not  press  on  the  ovaries,  afford  the 
greatest  relief.  If  this  condition  is  found  to  exist  after  a 
cul-de-sac  operation  is  made,  the  ovaries  should  be 
detached  from  their  false  attachments. 


Fig. 


31- 


-Right  pyosalpinx  and  ovarian  abscess.     Left  ruptured  ectopic 
gestation.     Left  ovarian  apoplexy.     Vaginal  ablation. 


Ovarian  sclerosis  cannot  be  cured  by  any  means. 
Such  ovaries  may  be  removed  when  indications  exist  for 
removing  the  uterus,  but  sclerosis  of  the  ovaries  only 
does  not  warrant  their  removal. 

Edonatoiis  ovaritis  I  have  not  met  with  except  under 
circumstances  which  required  removal  of  all  the  genera- 
tive organs. 

Cystic  Ovaries. — Upon  opening  the  cul-de-sac  I  first 
attempt  to  free  the  ovary  of  one  side.  When  this  is 
loose  I  introduce  a  posterior  retractor  into  the  pelvis,  and 
with  the  trowel  lift  the  uterus  into  the  abdomen.  A 
gauze  pad  is  next  introduced  between  the  retractors,  and 


112  PELVIC   INFLAMMATION. 

the  head  of  the  table  is  lowered.  If  the  intestines  are  not 
adherent  they  will  escape  into  the  abdomen.  The  ovary- 
is  now  grasped  with  Luer's  forceps  and  pulled  down. 
A  pair  of  stout  mouse-tooth  forceps  or  bullet  forceps 
may  be  substituted  for  Luer's  instrument.  The  surface 
of  the  ovary  is  inspected  carefully,  and  all  cysts  are 
stabbed  with  a  tenotomy  knife.  The  bleeding  is  trivial. 
When  all  the  cysts  are  evacuated,  the  ovary  is  returned 
to  the  pelvis  and  the  other  ovary  similarly  treated.  I  am 
opposed  to  igni-puncture  with  the  Paquelin  cautery. 
This  method  of  evacuation  is  uselessly  complicated,  and 
the  healing  after  it  is  not  normal.  After  returning  the 
ovaries,  the  pelvis   is  wiped   dry,  and  the   gauze  pad  is 


Fig.  32. — Suture  of  resection  wound  in  tlie  ovary. 

removed.  The  rent  in  the  cul-de-sac  is  sewed  up,  if  the 
uterus  is  not  retroposed,  if  the  patient  has  not  purulent 
endometritis,  and  if  there  is  not  pronounced  oozing  in 
the  pelvis.  When  either  of  these  exists  it  is  better  to 
introduce  a  plug  of  iodoform  gauze  into  the  opening  and 
pack  the  vagina. 

Ovarian  Apoplexy. — Having  released  the  ovary  from 
false  attachments,  it  is  pulled  into  the  vagina.  In  doing 
this  care  is  exercised  and  the  forceps  should  grasp  the 
more  normal  portions  of  the  organ.  Steadying  the  ovary 
the  surgeon  splits  the  periphery  of  the  blood-sac  with 
scissors.  Fluid  and  old  blood  escape  and  should  be 
caught  with  gauze.  Holding  apart  the  lips  of  the  rent, 
the  lining  cavity  of  the  sac  is  easily  pulled  out.  When 
this  is  removed  it  will  be  found  to  measure  sometimes  a 


INFLAMMATORY  DISEASES  OF  THE  OVARIES. 


^13 


sixteenth  of  an  inch  in  thickness.  The  cavity  left  after 
this  will  ooze  a  little,  and  the  organ  will  appear  much 
shrunk.  Nothing  more  is  needed  where  the  apoplexy  is 
small ;  but  where  the  accumulation  is  large  and  its  evacu- 
ation leaves  flabby  flaps,  these  should  be  trimmed  and 
sutured  (Fig.  32).  The  suture  material  may  be  either  fine 
chromic  kangaroo  tendon  or  fine  carbolized  silk.  The 
needles  should  penetrate  beneath  the  cavity  and  a  contin- 


FlG.  33. — Bilateral  purulent   salpingitis.      Bilateral  cystic  degeneration  ot 
ovaries,  the  right  large.     Vaginal  ablation. 


uous  suture  be  used.  The  ovary  is  returned,  and,  after 
cleansing  the  pelvis  and  removing  the  protecting  pads, 
the  opening  in  the  vagina  is  either  sutured  or  plugged 
with  gauze.  Of  course,  whenever  retroversion  accom- 
panies either  cystic  or  apoplectic  ovary,  the  cul-de-sac  is 
not  to  be  closed,  but  is  to  be  treated  according  to  the 
method  described  elsewhere  (see  page  117). 

Ovarian  Abscess. — The  treatment  of  this  is  similar  to 
that  of  pyosalpinx,  both  as  regards  palliative  operations 
and  extirpation  (Fig.  33). 


TT4 


PELVIC   INFLAMMATION. 


BROAD-LIGAMENT  CYST. 

Upon  examining  the  broad  ligament  spread  out  before 
a  strong  light,  the  various  component  parts  of  the  par- 


FiG.  34. — Diagram  of  the  structures  in  and  adjacent  to  the  broad  ligament. 
a,  Framework  of  the  parenchyma  of  the  ovary,  seat  of  ^,  simple  or  glandular 
multilocular  cyst;  c,  tissue  of  hilum,  with  d,  papillomatous  cyst;  e,  broad  liga- 
ment cyst,  independent  of  parovarium  and  Fallopian  tube;/^  a  similar  cyst  in 
broad  ligament  above  the  tube,  but  not  connected  with  it ;  h,  a  similar  cyst 
developed  close  to  ovarian  fimbria  of  tube  ;  /,  the  hydatid  of  Morgagni ;  k, 
cyst  developed  from  horizontal  tube  of  parovarium.  Cysts  e,  f,  h,J,  and  k 
are  always  lined  internally  with  a  simple  layer  of  endothelium.  /,  The  paro- 
varium ;  the  dotted  lines  represent  the  inner  portion,  always  more  or  less  obso- 
lete in  the  adult ;  m,  a  small  cyst  developed  from  a  vertical  tube ;  cysts  that 
have  this  origin,  or  that  spring  from  the  obsolete  portion,  have  a  lining  of 
cubical  or  ciliated  epithelium,  and  tend  to  develop  papillomatous  growths,  as 
do  cysts  in  c,  tissue  of  the  hilum  ;  n,  the  duct  of  Gartner,  often  persistent  in  the 
adult  as  a  fibrous  cord  ;  o,  track  of  that  duct  in  the  uterine  wall ;  unobliterated 
portions  are,  according  to  Coblenz,  the  origin  of  papillomatous  cysts  in  the 
uterus.     (After  Doran.) 


ovarium  may  be  seen  either  as  fibrous  cords  or  as  minute 
tubes  (Fig.  34).  Any  infection  passing  from  the  uterus  to 
the  iliac  glands  through  the  lymph  channels  in  the  broad 


BROAD-LIGAMENT   CYST.  u^ 

ligament  will  set  up  an  inflammation  in  one  or  more  of 
these  embryonic  tubes.  If  one  only  be  inflamed,  a  single 
broad  ligament  cyst  will  be  produced;  if  more  become  dis- 
tended, a  multiple  cyst  is  the  result.  Most  women  who 
have  suffered  infection  after  abortion  and  labor  will  in  time 
develop  one  or  more  such  cysts  of  greater  or  less  size. 
As  the  cysts  grow  they  spread  apart  the  folds  of  the  broad 
ligament.  They  have  no  pedicles.  At  first,  while  small 
and  if  situated  far  out  in  the  ligament,  they  can  be  moved 
with  the  ovary  and  tube ;  but  when  they  have  grown  to 
touch  the  side  of  the  uterus,  they  are  always  sessile  upon 
the  uterus.  Their  sacs  are  exceedingly  thin  and  are  easily 
ruptured.  The  fluid  in  them  is  perfectly  clear,  watery, 
and  of  a  pale  straw  color.  It  is  entirely  innocent  and 
devoid  of  harmful  properties.  Sometimes  these  tumors 
are  of  large  size,  reaching  even  to  the  umbilicus.  In 
growing  they  displace  the  uterus  laterally.  They  are 
never  of  acute  formation,  but  are  of  gradual  growth. 

Symptoms. — Whatever  distress  attaches  to  fixity  of 
the  uterus  and,  if  the  tumor  be  large,  to  the  presence  of 
a  mass,  accompanies  these  growths.  There  is  not  the 
pelvic  pain,  nor  the  fever,  nor  the  recurrent  inflammation 
which  accompany  pus  in  the  pelvis.  The  history  is  usu- 
ally that  of  a  mild  degree  of  infection  following  abortion 
or  labor.  Upon  examination  there  is  felt  upon  one  side 
of  the  uterus  a  very  fluid  tumor,  but  slightly  sensitive. 
The  uterus  is  firmly  fixed  to  the  tumor  and  may  be 
pushed  away  from  the  tumor  to  one  side  only.  The  arch 
of  the  base  of  the  broad  ligament  upon  the  side  of  the 
tumor  is  destroyed,  and  the  finger  when  swept  away  from 
the  cervix  on  the  tumor  side  appreciates  that  the  tumor 
and  uterus  are  but  one  mass.  This  is  an  invariable  sign 
of  all  broad  ligament  growths,  whether  fluid  or  solid, 
whenever  they  reach  the  side  of  the  uterus.  By  repeated 
attacks  of  peritonitis,  purulent  foci  in  the  ovary  and  tube 
may  imitate  this  relation ;  but  such  lesions  commonly 
occupy  a  position  further  behind  the  uterus.  Broad 
ligament  abscess  causes  the  general  symptoms  of  pus, 
while  ruptured  ectopic   gestation  and   broad   ligament 


.  Il6  PELVIC    INFLAMMATION. 

fibroid  are  much  firmer.  The  marked  fluidity,  the  thin- 
ness of  the  walls,  and  the  clinical  history  will  usually 
make  the  diagnosis  clear. 

Ti-catnieiit. — If  the  growths  are  small  and  purely 
pelvic  in  location,  they  are  easily  treated  through  the 
cul-de-sac.  But  where  they  are  large  and  extend  above 
the  pelvic  brim  they  should  be  removed  through  the 
abdomen.  Upon  opening  the  cul-de-sac  the  diagnosis 
is  easily  made.  A  gauze  pad  is  introduced  into  the 
pelvis  above  the  tumor,  and  the  head  of  the  table  low- 
ered. The  anterior  trowel  and  posterior  retractor  read- 
ily expose  the  tumor  to  view.  Its  surface  is  smooth  and 
glistening,  and  through  its  thin  sac  the  clear  fluid  is 
seen.  Having  inspected  the  tumor,  enough  gauze  pads 
are  introduced  into  the  pelvis  to  keep  all  intestines  above 
the  brim^  and  the  patient  is  brought  to  a  horizontal  posi- 
tion. A  pair  of  closed  blunt  scissors  are  shoved  into  the 
tumor,  and  its  contents  escape  through  the  vagina.  It  is 
the  posterior  layer  of  the  broad  ligament  which  is  punc- 
tured by  the  scissors.  As  the  scissors  are  withdrawn 
the  blades  are  opened  so  as  to  make  a  wide  rent  in  the 
sac.  The  pelvis  is  wiped  dry  and  the  finger  seeks  the 
opening  in  the  sac.  So  flimsy  are  its  walls  that  it  is  with 
difficulty  found,  but  when  entered  its  cavity  is  explored 
for  secondary  cysts.  These  are  ruptured.  Removing 
the  gauze  pads  from  the  pelvis,  the  surgeon  packs  the 
cul-de-sac  opening  with  iodoform  gauze  which  passes 
just  within  the  cut  edges  of  the  vagina.  The  uterus  is 
replaced  and  the  vagina  packed  with  gauze.  I  do  not 
pack  the  cyst  cavity.  It  closes  spontaneously  without 
artificial  drainage,  there  being  no  pus  present. 

The  first  dressing  is  made  in  seven  to  ten  days  and 
repeated  as  often  as  soiled.  After  the  second  dressing 
the  patient  is  allowed  out  of  bed. 


ADHERENT   RETROPOSITIONS. 


117 


ADHERENT  RETROPOSITIONS* 

While  this  book  does  not  treat  of  all  forms  of  displace- 
ment, there  is  one  so  commonly  associated  with  inflam- 
mation of  the  adnexa  that  I  may  describe  my  method  of 
dealing  with  it  through  the  vagina.  I  shall  exclude  from 
this  discussion  all  cases  of  congenital  displacement  and 


Fig.  35. — Retroveision  with  old  firm  adhesions  (Winckel). 


shall  deal  only  with  those  which  have  been  accom- 
panied or  caused  by  either  gonorrheic  or  septic  infection, 
for  I  believe  the  congenital  cases  are  incurable  (Fig.  35). 

The  difference  between  the  free  and  the  adherent  retro- 
positions  is  that  the  latter  are  complicated  by  false  bands 
which  bind  the  displaced  uterus  to  the  lower  and  pos- 
terior portions  of  the  pelvis,  and  also  commonly  present 
some  degree  of  tubal  disease. 

Before   any  attempt   at   replacement   of  an  adherent 


irS  TELVIC   INFLAMMATION. 

uterus  can  be  made,  the  false  bands  of  union  must  be 
severed.  This  can  be  done  in  one  of  two  ways:  either 
tlirough  the  abdomen  or  through  the  vagina.  If  the 
operation  is  performed  through  the  belly,  the  fundus 
uteri  is  suspended  from  the  anterior  abdominal  wall 
(Kelly's  method),  or  else  the  anterior  surface  of  the 
uterus  is  stitched  to  the  upper  wall  of  the  bladder 
(Pryor,  N.  Y.  Jour.  Gynec.  and  Obstet.,  July,  1893). 
Few  objections  can  be  made  to  either  operation,  except 
that  both  necessitate  an  invasion  of  the  abdominal  cavity 
and  conservative  treatment  of  the  inflamed  adnexa  is 
limited  in  scope.  Of  the  vaginal  methods  there  are 
two,  one  of  anterior  colpotomy  (Diihrssen-Machenrodt, 
etc.),  which  is  condemned  because  it  interferes  so  often 
with  subsequent  pregnancies;  and  the  other,  the  opera- 
tion I  have  for  years  been  performing.  I  have  been 
struck  with  the  invariable  observance  of  one  of  two 
rules  in  all  operations  which  succeed  in  keeping  a  retro- 
posed  uterus  forward:  either  this  is  accomplished  by 
fastening  the  corpus  uteri  forward,  or  else  by  fixing  the 
cervix  high  and  backward  so  that  the  intra-abdominal 
pressure  will  force  the  body  of  the  utorus  forward.  This 
latter  is  the  way  a  pessary  acts,  and  this  is  the  idea 
embodied  in  my  operation. 

Operation. — The  patient  is  prepared  locally  and  gen- 
erally as  for  a  capital  operation.  I  begin  the  operation 
with  a  curettage.  The  cul-de-sac  is  then  opened  (see 
Exploration).  Upon  entering  the  pelvic  cavity  I  make 
a  careful  digital  exploration.  If  I  find  a  pus  focus. 
/  abandon  all  ficrther  attempts  at  replacement  by  the 
vagina,  and  treat  the  case  as  one  of  suppuration.  But  if 
I  find  any  condition  of  the  adnexa  that  will  not  require 
their  removal  (see  Conservatism),  I  continue  the  opera- 
tion. Occluded  tubes  are  opened  and  other  adhesions 
are  severed.  The  pelvis  is  then  wiped  dry,  and  a  gauze 
pad  inserted.  The  patient  is  tilted  into  the  Trendelen- 
burg posture  and  the  gauze  pad  is  removed.  The 
uterus  is  packed  with  iodoform  gauze.  The  operator 
selects  a  piece  of  iodoform  gauze  wide  enough  to  fill 


ADHERENT   RETROPOSITIONS. 


119 


the  vaginal  opening  and  about  one  and  a  lialf  inches 
long.  This  is  inserted  just  ivitliin  the  edges  of  the 
vaginal  rent.  Over  this  enough  strips  are  placed  to  fill 
the  incision  in  the  vagina.  This  gauze  plug,  together 
with  the  uterus,  is  next  replaced.  It  is  easily  done,  as 
the  patient  is  head  down  and  the  intestines  have  left  the 
pelvis.  Holding  the  uterus  in  position,  by  means  of  the 
trowel  or  any  depressor  pushing  against  the  cervix, 
pieces  of  gauze  are  inserted  to  the  sides  of  the  cervix 
and  in  front  of  it  until  the  vagina  is  filled  to  the  margin 
of  the  levator  ani  muscle.  The  operator  now  takes  a 
stout  roll  of  gauze  as  thick  as  his  thumb  and  as  long  as 
the  width  of  the  distended  vagina,  usually  two  inches. 
This  I  call  my  gauze  pessary.  One  end  of  this  is  intro- 
duced in  front  of  one  side  of  the  cervix,  just  behind  the 
levator  ani  fibers,  and  the  other  end  is  pushed  into  a 
similar  position  on  the  other  side.  This  plug  will  lie 
transversely  across  the  vagina  and  in  front  of  the  cervix. 
(Fig.  36).  It  will  prevent  descent  of  the  cervix  even  in 
face  of  the  most  violent  vomiting.  The  uterine  packing 
should  be  so  arranged  that  it  can  be  removed  without 
disturbing  this  anchoring  plug. 

A  self-retaining  catheter  is  introduced  and  is  emptied 
every  two  hours  for  two  days.  The  bladder  is  then 
irrigated  with  boric  acid  solution  and  the  catheter  with- 
drawn. The  uterine  packing  is  now  removed  without 
disturbing  the  vaginal.  In  seven  to  ten  days  the  patient 
is  placed  in  Sims'  position.  All  dressings  are  removed 
and  replaced  exactly  as  were  the  first.  The  operation 
will  fail  unless  the  supporting  plug  is  properly  inserted. 
This  is  as  important  as  the  suture  in  other  operations. 
The  second  dressing  is  applied  a  week  later,  is  painless, 
and  after  it  the  patient  sits  up.  I  keep  up  these  dress- 
ings as  long  as  there  is  any  raw  surface  at  the  vaginal 
vault;  the  supporting  tamponade  I  use  for  six  weeks. 
The  woman  is  then  allowed  intercourse. 

If  at  any  time  the  dressings  are  so  applied  that  they 
allow  of  descent  of  the  uterus,  they  have  been  improperly 
inserted.     The  cervix  must  be  kept  high  and  backward 


PELVIC   INFLAMMATION. 


until  the  cul-de-sac  opening  closes  and  the  post-cervical 
scar  has  contracted.  The  operation  leaves  the  corpus 
uteri  perfectly  free.  Pregnancy  resulting  after  the  oper- 
ation is  uninterrupted,  and  labor  is  normal.  Lacerations 
and   disease'lin  the  cervix   and   perineum  are  to  be  cor- 


FiG.  36. — Showing  schematically  the  position  of  the  dressings  in  tlic 
cul-de-sac  operation  of  replacement. 


rected  after  the  patient  has  recovered  from  the  replace- 
ment operation,  and  are  made  purely  to  supplement  the 
first  operation.     The  rules  governing  these  plastic  oper- 
ations are  the  same  as  apply  after  hysterorrhaphy,  etc. 
The  operation  in  my  hands  takes  the  place  of  all  other 


r,ROAD-T,K;AMENT   AltSCESS.  121 

operations.  It  has  a  wider  range  of  application  than  any 
other  procedure,  and  can  be  used  in  all  cases  not  pre- 
senting pus.  When  the  retroposition  is  accompanied  by- 
occluded  tubes,  by  hydrosalpinx,  by  cystic  ovaries,  etc., 
this  is  the  preferable  operation.  But  when  pus  is  pres- 
ent in  either  ovary  or  tube  removal  of  this  and  replace- 
ment can  only  be  accomplished  by  laparotomy. 


BROAD-LIGAMENT  ABSCESS. 

This  rare  condition  almost  invariably  follows  labor  or 
abortion.  The  infection  passes  along  the  lymph  streams 
between  the  folds  of  the  broad  ligament,  and  causes  sup- 
puration there.  The  pus  forms  very  slowly  usually.  In 
the  epidemic  of  puerperal  fever  which  occurred  in  New 
York  in  1881-82,  the  author  saw  a  great  many  of  these 
cases,  but  they  are  now  comparatively  rare.  I  have  met 
with  but  six  in  the  last  1,000  clinic  cases.  As  the  pus 
accumulates,  it  separates  the  folds  of  the  broad  ligament. 
The  bladder  in  front  prevents  much  bulging  anteriorly, 
so  the  greater  part  of  the  distention  of  the  broad  liga- 
ment is  posteriorly.  As  this  grows  larger,  the  periton- 
eum is  stripped  from  the  posterior  surface  of  the  uterus 
and  is  lifted  up  ;  the  peritoneum  of  the  pelvic  floor  behind 
the  broad  ligament  is  also  lifted,  and  the  masses  may  be  so 
large  as  to  reach  Poupart's  ligament.  The  fluid  is  essen- 
tially extraperitoneal.  It  is  suppuration  in  continuity  of 
tissue,  and  is  far  different  in  all  its  bearings  from  suppu- 
ration in  a  preformed  sac  (pyosalpinx).  Coexistent  with 
this  formation,  there  is  a  great  amount  of  peritonitic  ef- 
fusion about  the  broad  ligament.  There  may  also  be  a 
pyosalpinx  or  ovarian  abscess  present.  After  the  abscess 
reaches  a  large  size,  the  gross  lesion  presented  is  of  an 
abscess  cavity  lying  upon  the  pelvic  floor,  to  one  side  of 
which  is  the  displaced  uterus,  and  above  which  lies  the 
matted  mass  of  omentum  and  intestines.  In  rare  cases 
the  abscess   is  bilateral.     In  such   the  pus  may  extend 


122  PELVIC   INFLAMMATION. 

in  front  of  the  uterus  and   between  tlie  bladder,  so  that 
the  two  abscesses  communicate. 

Symptoms. — These  are  at  first  not  suj^gestive  of  broad 
ligament  abscess.  After  a  long  attack  of  continuous 
pelvic  inflammation,  in  the  course  of  which  there  have 
been  many  rigors  and  violent  fluctuations  in  tempera- 
ture, this  condition  may  be  suspected.  Upon  examina- 
tion, the  uterus  is  found  crowded  up  high  and  to  one 
side.  It  is  sometimes  so  displaced  that  the  cervix  can- 
not be  felt.  Extending  from  the  side  of  the  uterus  to  the 
lateral  pelvic  wall  is  a  large  mass,  tense  and  fluctuating. 
This  mass  is  sessile  upon  the  uterus,  i.  c,  there  is  no 
sulcus  between  the  mass  and  the  uterus.  It  is  immovable 
and  fixes  the  uterus.  It  projects  in  all  directions  when 
large,  and  can  be  felt  behind  the  bladder,  above  Poupart's 
ligament  and  deep  in  the  pelvic  floor.  There  are  evi- 
dences of  a  severe  type  of  pelvic  inflammation.  The 
bladder  is  capable  of  holding  but  a  few  ounces  of  urine 
when  the  abscess  is  large,  and  the  lumen  of  the  rectum 
is  almost  closed.  Upon  rectal  examination,  the  mass  is 
found  apparently  attached  to  the  rectum  if  it  has  stripped 
up  the  pelvic  floor.  About  the  only  conditions  simu- 
lating this  are,  dermoid  cysts,  ectopic  gestation  ruptured 
and  septic,  and  broad  ligament  cyst.  But  the  history  of 
a  labor  or  abortion,  long-continued  sepsis,  and  a  gradu- 
ally enlarging  tumor,  which  is  always  sessile,  even  when 
small,  and  which  undoubtedly  occupies  the  broad  liga- 
ment, will  render  the  diagnosis  clear.  When  the  accu- 
mulation is  small,  the  finger  readily  enters  the  incised 
cul-de-sac.  The  enlargement  is  found  to  be  upon  one 
side  of  the  uterus,  and  the  posterior  wall  of  the  broad 
ligament  bulges  backwards.  A  slight  pressure  against 
the  mass  suffices  to  evacuate  the  pus,  rendering  the  diag- 
nosis clear.  With  this  pus  formation,  there  has  been 
much  peritonitis,  and  the  examining  finger  evacuates 
the  lymph  and  serum  produced  by  this.  The  pelvic 
viscera,  where  they  can  be  reached,  are  found  matted  to- 
gether. The  ovary  and  tube  upon  the  affected  side  are 
raised  high  in  the  pelvis.  When  the  abscess  is  large,  the 


DIFFUSE   PELVIC   SUPPURATION. 


123 


finger  cannot  be  made  to  enter  the  cul-de-sac  at  all ;  and 
upon  incising  the  vaginal  mucosa,  the  finger  enters  a 
cavity  of  loose  cellular  tissue  which  bleeds  freely.  This 
is  produced  by  the  abscess  lifting  the  peritoneum  from 
the  pelvic  floor.  After  inserting  the  finger  behind  the 
uterus  up  to  the  level  of  the  internal  os,  it  will  enter  the 
pus  sac  at  once,  or  will  find  it  if  turned  laterally  toward 
the  fluid  mass. 

This  lifting  of  the  pelvic  peritoneum  is  characteristic 
of  all  large  broad  ligament  accumulations. 

Treatment. — All  these  accumulations  should  be 
treated  through  the  vagina.  They  should  be  opened 
through  the  posterior  cul-de-sac  and  evacuated.  For  this 
purpose  the  fingers  alone  are  to  be  used  after  the  vaginal 
wall  is  incised,  as  the  position  of  the  vessels  is  not  con- 
stant. If  the  cul-de-sac  is  entered  before  the  abscess  is 
emptied,  it,  as  well  as  the  abscess  cavity,  must  be  packed 
with  gauze.  If  the  examining  finger  enters  at  once  into 
the  pus  cavity,  it  is  to  be  widely  stretched  and  packed. 
The  after  dressings  are  governed  by  the  amount  of  dis- 
charge and  the  temperature.  It  is  wise  to  curette  the 
uterus  before  opening  the  cul-de-sac.  After  dressing  the 
abscess  cavity  the  uterus  is  to  be  packed  with  iodoform 
gauze,  which  in  two  days  is  withdrawn. 


DIFFUSE  PELVIC  SUPPURATION. 

This  must  not  be  confounded  with  primary  purulent 
peritonitis.  There  has  been  suppuration  in  either  the 
ovary,  the  tube,  or  the  broad  ligament.  Accompanying 
this  there  has  been  a  virulent  form  of  peritonitis,  and  a 
great  outpouring  of  plastic  lymph  has  ensued.  Some- 
times this  lymph  breaks  down  into  pus;  in  other  cases 
the  original  pus  focus  leaks  into  the  lymph  masses.  As 
a  result  the  pus  has  ceased  to  be  confined  in  either  tube, 
ovary,  or  broad  ligament,  but  has  wormed  its  way  be- 
tween adherent  lymph  planes,  omentum,  and  intestines. 


J  24  PELVIC   INFLAMMATION. 

More  lymph  is  jiroduccd,  and  wider  burrowing  of  pus 
ensues,  thus  presenting  a  picture  of  indistinguishable 
organs  within  and  between  which  are  pus  pockets  and 
connecting  sinuses.     This  is  diffuse  suppuration. 

Syinptoius. — The  history  is  usually  one  of  prolonged 
suffering,  recurrent  attacks  of  peritonitis,  emaciation,  and 
hopelessness.  The  woman  is  practically  bed-ridden. 
Upon  examination  the  uterus  is  found  firmly  imbedded 
in  a  mass  of  exudate.  The  uterus,  ovaries,  tubes,  and 
other  pelvic  organs  form  one  dense  conglomerate  rnass. 
The  diagnosis  from  small  fibroid  or  ruptured  ectopic 
pregnancy  with  pus  is  impossible.  Broad  ligament 
cysts,  ovarian  tumors,  simple  fibroids,  etc.,  do  not  present 
the  immobile  sensitive  uterus,  profound  sepsis,  emacia- 
tion, and  mal-nutrition  which  accompany  diffuse  suppu- 
ration. Nephritis  and  phthisis  are  common  accompani- 
ments. I  have  usually  found  the  rectum  permanently 
distended  in  these  cases.     It  cannot  contract. 

Very  often  sinuses  form  between  the  bowel  and  the  pus 
foci,  affording  a  temporary  relief  when  the  pus  escapes 
into  the  gut,  followed  by  gi-eat  increase  in  the  lesions 
from  contamination  by  bowel  filth. 

Upon  opening  the  cul-de-sac,  the  finger  at  once  evacu- 
ates pus  lying  free  in  the  pelvis.  The  exploration  is 
purely  digital,  and  as  the  finger  maps  out  the  various 
organs  it  enters  pocket  after  pocket  of  pus.  The  livid 
lymph-covered  intestines  are  found  low  down  usually, 
pressed  down  by  tympanites,  and  tend  to  protrude  into 
the  vagina  when  freed.  Above  the  uterus  and  adnexa  is 
an  impenetrable  dome  of  matted  intestines  and  omentum. 

Treatment. — Many  of  these  women  are  so  critically 
ill  that  a  radical  operation  is  contraindicated.  The  first 
step  is  usually  to  inject  a  quart  of  sterile  and  filtered 
normal  salt-solution  into  the  elbow  vein.  The  uterus  is 
curetted.  The  cul-de-sac  is  opened,  and  all  pus  pockets 
emptied.  The  pelvis  is  wiped  dry  with  gauze.  Irriga- 
tion should  never  be  employed  for  this  purpose,  lest  the 
pus  be  washed  into  the  higher  pelvis  and  abdomen. 
After  evacuating  all   the    pus   cavities   and  thoroughly 


ANESTHETIC. 


125 


cleansing  the  pelvis,  the  dressing  is  made.  The  long 
perineal  retractor  draws  down  the  posterior  vaginal  wall 
while  the  trowel  lifts  up  the  uterus.  An  abundance  of 
light  is  by  this  means  thrown  into  the  pelvis,  and  the 
gauze  can  be  inserted  between  two  smooth  metal  planes. 
Each  piece  of  iodoform  gauze  is  three  inches  wide  and 
a  yard  long.  It  is  folded  many  times,  and  is  inserted 
up  to  the  level  of  the  fundus  uteri.  With  a  lateral 
retraqtor  this  piece  is  pulled  to  one  side  while  another  is 
inserted,  and  progressively  the  pelvis  is  filled. 

The  first  dressing  will  not  require  narcosis,  and  should 
be  made  as  soon  as  the  temperature  rises.  The  opening 
is  kept  carefully  packed  until  it  is  closed  by  granulation. 
Every  pocket  of  pus  is  sought  out  and  entered.  Its  sac 
is  widely  opened  by  the  finger,  and  after  swabbing  it  dry 
it  is  packed.  The  operator  must  not  fail  to  insert  a  stout 
gauze  drain  into  every  pus  pocket. 

This  operation  is  purely  palliative,  and  a  relapse  is  to 
be  expected.  But  before  this  occurs  the  case  can  be 
carefully  prepared  for  a  radical  operation.  After  the 
general  condition  has  been  improved  the  uterus,  ovaries, 
and  the  tubes  are  to  be  removed  through  the  vagina  by 
hemisection. 


ANESTHETIC 


The  vaginal  operations  do  not  demand  that  complete 
physical  relaxation  which  is  essential  in  laparotomy.  An 
incomplete  narcosis  is  sufficient,  and  chloroform  again 
becomes  the  preferable  anesthetic.  I  have  extensively 
tried  the  Schleich  mixture,  but  have  returned  to  chloro- 
form and  ether.  I  always  administer  chloroform  upon 
an  Esmarch  mask,  and  usually  precede  it  by  a  hypoder- 
mic of  strychnin,  gr.  5^.  Ether  I  give  through  a  Sims' 
inhaler,  sterile  gauze  being  employed  to  hold  the  anes- 
thetic. The  cones  with  bag  attachments  I  have  thought 
conduced  to  th^  occurrence  of  pneumonia. 


126  PELVIC  INFLAMMATION. 


CURETTAGE. 

The  patient,  having  previously  been  prepared,  is 
placed  upon  the  back  in  the  lithotomy  position.  The 
perineum  is  retracted  with  a  short  speculum,  or  the 
cervix  may  be  exposed  by  means  of  a  bivalve  speculum. 
If  the  latter  be  used  its  blades  must  be  short.  The  cervix 
is  next  seized  with  a  pair  of  blunt  bullet  forceps  fastened 
into  the  anterior  lip,  and  the  cervix  is  gently  drawn  down. 
This  at  once  brings  the  cervix  nearer  and  straightens  the 
canal  very  materially.  The  direction  and  depth  of  the  canal 
are  determined  by  the  sound.  The  dilator  is  introduced, 
the  cervix  being  still  firmly  held  (Fig.  37).  In  selecting  a 
dilator  the  operator  should  avoid  those  operated  by  screws. 
These  are  positively  dangerous,  inasmuch  as  the  force  can 
not  be  released  if  tearing  begins,  so  that  rupture  of  the 
cervix  may  be  produced.  Some  modification  of  Sims' 
instrument  is  best.  If  the  cervix  is  so  stenosed  that  the 
dilator  cannot  be  introduced,  I  do  not  hesitate  to  enlarge 
the  canal  with  a  blunt  bistory,  cutting  bilaterally.  The 
dilatation  is  done  progressively,  the  force  being  inter- 
mittent and  the  dilator  turned  a  little  from  side  to  side. 
The  dilatation  in  all  cases  reaches  a  half  inch,  and  greater 
space  is  secured  in  many  cases.  The  larger  the  cavity  to 
be  scraped,  the  more  open  should  be  the  cervix.  If  the 
dilatation  is  properly  done  and  a  good  deal  of  traumatism 
inflicted  upon  the  cervix,  the  cervical  ganglia  are  obtunded, 
and  uterine  contractions  with  expulsion  of  the  dressings 
do  not  follow  the  operation.  Having  dilated  the  cervix 
the  uterus  is  to  be  curetted.  I  use  the  sharp  instrument 
of  Sims,  and  prefer  a  small  one  for  hard  uteri  and  a  large 
one  for  soft  organs.  The  curette  is  introduced  to  the 
fundus  gently,  and  the  force  is  used  in  withdrawing  the 
instrument.  The  pressure  is  made  all  along  the  instru- 
ment, and  the  cervix  must  not  be  used  as  a  fulcrum.  The 
operator  proceeds  all  around  the  inside  of  the  uterus, 


Fig.  37. — Demonstrating  the  method  of  dilating  the  cervix  preliminary  to 
curetting' the  uterus. 


CURETTAGE. 


1  29 


paying  particular  attention  to  the  lateral  angles  and  tubal 
openings.  The  fundus  is  scraped  by  sweeping  the  curette 
from  one  tubal  orifice  to  the  other  several  times.  The 
uterus  may  now  be  irrigated  with  saturated  solution  of 
boric  acid  or  normal  salt-solution.  The  ordinary  fountain 
syringe  is  the  best  irrigator  (see  page  devoted  to  steriliza- 
tion). I  employ  the  Fritsch-Bozeman  double  current 
catheters.  If  the  debris  removed  by  the  curette  are  small 
they  are  readily  washed  out,  but  large  plugs  of  tissue 
must  be  wiped  away.  To  accomplish  this  the  uterus  is 
packed  with  gauze  and  the  dressing  is  made  to  revolve 
within  the  uterus  by  means  of  a  tampon  screw.  When 
it  is  withdrawn,  all  portions  of  membrane  are  caught  in 
the  folds  of  the  gauze.  I  have  abandoned  irrigation  ot 
the  uterus  where  the  organ  is  small  and  a  small  irrigating 
tube  must  be  used.  Instead  I  swab  out  the  cavity  by 
iodoform  gauze.  The  sole  object  is  to  remove  all  debris 
produced  by  the  curette.  In  many  irrigated  cases  where  I 
have  opened  the  cul- de-sac,  I  have  found  fluid  in  the 
pelvis  which  was  blood-stained.  I  have  thought  that 
perhaps  in  certain  cases  of  small  uteri  the  irrigating  fluid 
may  have  escaped  into  the  pelvic  cavity  through  the  tubes. 
Having  cleansed  the  uterus,  it  is  next  packed  with  gauze. 
I  use  for  this  purpose  a  stout  metal  applicator  which  is 
slightly  curved.  The  gauze  is  folded  over  the  end,  and  is 
fed  into  the  uterus  by  means  of  successive  holds  with  the 
applicator.  The  tampon  screw  can  be  used  for  the  same 
purpose  (Fig.  38).  The  organ  should  be  completely  filled. 
The  object  of  this  is  to  have  within  the  uterus  a  sufficient 
amount  of  dressing  to  exert  pressure,  to  absorb  all  dis- 
charges, and  to  act  as  a  protection  to  the  repair-cells 
while  they  are  forming  a  new  membrane.  The  first  few 
days  are  the  most  critical  in  this  matter.  If  the  repair  is 
started  properly,  it  will  proceed  to  the  formation  of  a  his- 
tologically perfect  membrane.  But  if  the  first  emigrated 
cells  are  destroyed,  either  by  iodin,  carbolic  acid  or  by 
infection,  a  distorted  endometrium  results,  which  will  pro- 
duce painful  menstruation  and  sterility.  Asepsis  of  the 
most  precise  nature  is  the  only  method  to  bring  success. 
9 


I30 


PELVIC   INKL\MMATION. 


It  will  not  suffice  merely  to  remove  the  endometrium  ; 
the  zinc  pencil  will  do  that.  But  the  removal  and  treat- 
ment must  be  so  done  as  to  insure  a  reproduction  of  a 
perfect  new  membrane.  That  is  impossible  when  even 
mild  sepsis  follows  the  operation.  As  antiseptics  destroy 
cells  they  should  never  be  used  within  the  uterine  cavity, 
for  dead  cells  disturb  healing  and  furnish  the  most  pro- 
pitious culture  medium  for  germs.  Antiseptics  have  no 
place  in  cavity  work  like  this.  Some  of  the  worst  cases 
of  dysmenorrhea  and  pelvic  neuritis  I  have  found  in  women 
who  have  been  curetted  by  careful  men,  men  perfectly 
cleanly  in  their  methods,  but  who,  believing  the  endome- 
trium to  be  a  mucous  membrane,  have  painted  it  with 
carbolic  acid,  thereby  promoting  the  production  of  scar 
tissue  within  the  uterus  without  a  trace  of  lymphoid  ele- 
ments. The  operation  of  curettage  must  be  done  with  a 
knowledge  of  the  anatomy  of  the  uterus  and  a  conscious- 
ness of  its  function. 

The  vagina  is  usually  packed  with  iodoform  gauze. 
If  uterine  cramps  follow  the  operation  a  suppository  of 
ext.  opii  and  ext.  belladonna,  each  gr.  i^,  may  be  given. 
The  vaginal  gauze  is  removed  on  the  third  day  and  the 
uterine  packing  withdrawn.  The  uterus  is  neither  irri- 
gated nor  again  packed,  but  the  vagina  is  packed  again, 
and  the  woman  allowed  out  of  bed,  provided  the  curet- 
tage has  been  done  for  an  uncomplicated  endometritis. 
The  bowels  are  moved  on  the  third  day.  The  vaginal 
dressings  are  removed  once  in  four  days  for  two  weeks, 
and  then  all  treatment  ceases.  A  new  endometrium  forms 
in  from  four  to  six  weeks.  Douching  and  amatory  ap- 
proaches from  the  male  are  forbidden  until  after  the  period 
following  the  operation.  Such  is  the  usual  course  and 
the  usual  operation. 

Time  for  Operating. — Preferably  one  week  after  men- 
struation is  the  elective  time.  The  special  conditions 
under  which  the  operation  is  done  will  modify  this  and 
may  be  referred  to. 

Infected  Cei'vix. — When  I  operate  in  acutely  inflamed 
cases  and  when  the  cervix  is  the  seat  of  gonorrhea,  I 


Fig.  38.— Packing  the  uterus  with  iodoform  o-a 


CURETTAGE. 


UZ 


always  paint  its  cavity  with  pure  carbolic  acid,  both  before 
and  after  dilating.  Equal  parts  of  tinct.  iodin  and  car- 
bolic acid  make  a  powerful  antiseptic.  In  using  these 
caustics  care  must  be  exercised  not  to  allow  of  the  pas- 
sage of  a  particle  into  the  uterine  cavity  above  the 
internal  os.  The  carbolic  does  not  cause  sloughing  in 
the  cervix,  because  its  lining  membrane  is  a  very  dense 
mucous  structure.  I  consider  it  exceedingly  important 
to  sterilize  the  cervix  in  all  gonorrheal  cases.  The  best 
means  of  doing  this  is  by  means  of  carbolic  applied  before 
the  glands  are  emptied  by  pressure  and  after. 

Repeated  Irrigations. — Whenever  I  have  to  deal 
with  a  large  acutely  infected  uterus,  and  especially  if 
there  be  peritoneal  or  adnexal  lesions  beginning,  I  deem 
it  necessary  to  irrigate  the  uterus  when  I  withdraw  the 
uterine  packing.  In  these  cases  the  infection  is  usually 
deeper  than  the  surface,  and  repeated  washings  with  boric 
acid  may  be  necessary  during  the  process  of  repair.  After 
washing  out  the  uterus  a  filament  of  gauze  is  introduced 
to  the  fundus  and  the  vagina  again  packed.  The  filament 
of  gauze  ensures  an  open  cervix.  I  remove  this  second 
dressing  in  three  days,  and  am  governed  by  the  appear- 
ance of  the  discharges  as  to  whether  I  shall  repeat  the 
washing  or  not.  If  puSj  or  even  broken-down  material 
in  quantity,  follows  the  withdrawal  of  the  second  gauze, 
I  again  wash  and  pack  as  a  precaution  against  re-infec- 
tion. Cases  which  are  infected  post  abortum  or  post 
partum  always  need  at  least  one  renewal  of  the  washing 
and  uterine  drain. 

Gonorrheal  cases  and  those  infected  by  uterine  tinker- 
ing sometimes  require  this  washing.but  no  packing  after 
the  first  dressings  are  removed.  It  is  almost  needless  to 
caution  the  operator  regarding  cleanliness  all  during  the 
treatment.  The  sterilization  must  be  as  complete  at 
dressings  as  at  the  operation. 

The  two  causes  for  infection  after  curettage  I  have 
found  to  be  in  the  faulty  removal  of  debris  and  the  appli- 
cation of  escharotic  antiseptics.  So  long  as  the  operation 
performed  has  these  two  attributes,  of  course  the  question 


T34 


PELVIC   INFLAMMATION. 


will  arise,  Does  gauze  drain  or  not?  Thus  far  1  have  not 
found  it  necessary  to  concern  myself  with  this,  but  I  may 
answer  the  question.     Gauze  does  drain,  for  the  vaginal 

packing  is  often  wet  through 
with  secretions  such  as  are 
found  in  the  uterine  packing. 

Quantity  of  Gauze  in  Ute- 
rus.— The  girl's  uterus  measur- 
ing three  inches  will  hold  a 
strip  of  gauze  one  inch  wide  and 
a  yard  long.  The  uterus  aborted 
at  the  third  month  will  contain 
a  strip  four  inches  wide  and  a 
yard  long.  The  full  term  uterus 
will  receive  a  roll  of  gauze  one 
yard  wide  and  five  yards  long. 
The  Instruments. — I  prefer 
the  short  specula  of  Jackson 
(Fig.  39).  They  are  simple, 
depress  the  perineum  properly, 
and  are  as  useful  when  laparo- 
tomy or  vaginal  hysterectomy 
is  done  as  in  curettage.  The 
traction  forceps  should  be  very 
dull  (Fig.  40),  so  as  not  to  tear 
the  tissues.  I  can  see  no  neces- 
sity for  the  multitude  of  dilat- 
ors offered  for  sale  (Fig.  41).  The  instrument  of  Sims', 
roughened  as  I  have  had  done,  is  sufficient.     Dilatation 


Fig.  39. — Jackson  speculum. 


Fig.  40. — The  author's  bkuit  bullet  forceps. 

by  graduated  bougies  is  always  imperfect.     The  bougies 
are  shoved  in  against  the  force  of  the  traction  forceps,  and 


CURETTAGE. 


135 


Fig.  41. — The  author's  uterine  dilator, 

dilatation  is  effected  by  shoving  up 
against  the  pulHng  down.  The  pro- 
cedure has  always  seemed  to  me  a  bit 
ridiculous.  The  curettes  are  of  Sims' 
pattern  (Fig.  42).  They  are  all  sharp, 
and  the  staff  while  stiff  can  be  bent 


Fig.  42. — Sims'  curettes.    Showing  the  blades  only. 

to  operate  in  very  flexed  organs.  The 
instrument  of  Recamier  has  too  long 
a  curetting  surface.  I  have  abandoned 
the  cervical  specula  through  which  to 
pack  the  uterus  (Fig.  43),  The  heavy 
applicator  can  be  adj  usted  to  the  curves 
of  the  organ,  and  with  it  I  pack  more 

thoroughly  than    is    possible  with    the  tra-uterine     ird- 

speculum.   I  always  use  a  double  cur-  s^tors 


Fig.  45.— Four 
calibres  of  the  in- 


FlG.  44. — Fritsch-Bozeman  double-current  irrigating  tubes. 


PELVIC   INFLAMMATION. 


rent  irritjating  tube  (Fig.  44).  It  is  improper  to  inject 
irrigating  fluid  into  the  uterus  with  a  bulb  syringe. 
Such  an  instrument  can  not  be  cleansed,  and  no  pro- 
vision is  made  in  it  for  the  return  of  the  fluid.  I  use 
the  Fritsch-Bozeman  uterine  irrigator. 


EXPLORATORY  VAGINAL  SECTION. 

The  bar  to  a  thorough  inspection  of  the  pelvic  cavity 
through  the  vagina  is  the  uterus;  and  a  great  embar- 
rassment experienced  in  the  procedure  is  prolapse 
of  the  intestines  into  the  vagina.  If  a  posture  can  be 
secured  which  will  prevent  the  latter,  and  an  incision 
adopted  which  will  remove  the  uterus  out  of  the  way 
without  injuring  it,  vaginal  exploration  of  the  pelvis  will 
supersede  the  abdominal.  The  author  believes  that  his 
procedure  secures  both  the  desirable  factors  essential  to 
success. 

It  must  be  remembered  that  the  distance  from  the 
vulva  to  the  cul-de-sac  is  even  less  than  from  the  abdo- 
men. Therefore  the  cavity  explored  from  below  is  not 
as  deep  as  when  sought  from  above.  The  ability  to  see 
the  pelvic  structures  through  the  vagina  is  then  depen- 
dent upon  the  space  secured.  The  space  is  not  so  much 
limited  by  the  vulva  as  by  the  condition  of  the  tissues 
about  the  cervix.  If  the  vaginal  incision  posterior  to  the 
cervix  is  one  and  a  half  inches  from  side  to  side,  the 
elastic  tissue  will  yield  under  the  pressure  of  the  retrac- 
tors to  make  the  opening  at  least  one  and  a  half  inches 
wide  by  over  two  inches  antero-posteriorly.  But  in  the 
rare  cases  of  pronounced  sclerosis  the  elasticity  of  the 
vaginal  vault  may  be  found  so  limited  that  sufficient 
space  cannot  be  secured  through  which  to  make  an  ade- 
quate visual  inspection.  The  operator  will  then  have  to 
depend  wholly  upon  his  sense  of  touch.  Still  this  con- 
tingency is  not  as  often  met  in  the  vaginal  operation  as 
in  the  abdominal. 


EXPLORATORY    VACCINAL   SECTION. 


'37 


Opei'Jitioii. — The  local  and  general  preparation  of  the 
patient  will  be  found  on  pages  i6i  to  163.  The  patient 
is  placed  upon  the  (Fig.  47)  table  in  the  lithotomy  pos- 


FlG.  47. — The  cul-de-sac  is  opened.  The  posterior  vaginal  wall  is  held 
down  by  the  retractor,  while  with  the  trowel  the  uterus  is  shoved  up  against 
the  bladder.  The  space  obtained  is  estimated  by  comparing  the  length  of  the 
operator's  index  finger  with  the  distance  between  the  blades  of  the  retractors. 
In  this  case  it  was  2I  inches. 


ture,  with  the  ischial  tuberosities  over  the  edge  of  the 
table.  The  perineum  is  retracted  by  a  short  Jackson 
speculum,  and  the  uterus  is  pulled  down.  The  uterus 
is  curetted  and  swabbed  out,  but  not  packed  with  gauze. 
The  vagina  is  wiped  dry.  Upon  shoving  the  cervix 
upward  a  fold  will  be  seen  to  form  just  opposite  the  cer- 
vico-vaginal  junction  (Fig.  48).  The  vagina  is  incised 
here,  scissors  being  used  for  the  purpose.     The  scissors 


I -.8 


PELVIC  INFLAMMATION. 


cut  through  vaginal  mucous  membrane  only.  The  inci- 
sion is  commonly  an  inch  long  and  extends  to  the  lateral 
borders  of  the  cervix  (Figs.  49,  50).      There  now  remains 


Fig.  48. — The  fold  behind  die    cervix  wliich  lies    over    the    cervico-vaginal 
junction  is  well  shown.     The  vagina  is  to  be  incised  here  (from  life). 


but  one  layer  of  tissue  to  sever, — the  peritoneum.  The 
uterus  is  held  firmly  down,  and  the  operator  pushes 
his  index  finger  into  the  cul-de-sac.  In  doing  this 
he  is  careful   to  keep  the  point  of  the  finger  accurately 


EXPLORATORY   VAGINAL   SECTION. 


139 


in  the  middle  line  and  pressed  up  against  the  posterior 
uterine  wall.  If  after  pushing  the  tissues  up  to  the  level 
of  the  internal  os  the  finger  has  not  entered  the  periton- 
eal cavity,  the  point  of  the  finger  is  directed  backwards 


Fig.  49. — The  vagina  is  incised,  and  the  point  at  which  the  peritoneum  is 
reflected  from  tlie  uterus  is  shown  as  the  deepest  part  of  tiae  cut.  The  peri- 
toneum is  to  be  torn  tlirough  at  this  point  (from  life). 

and  pushed  into  the  cavity.  If  the  peritoneum  is  very 
thick  it  is  caught  with  toothed  forceps  and  incised  with 
scissors.  Commonly  serum  escapes  when  the  cavity  is 
entered. 


l^o  PELVIC   INFLAMMATION. 

In  making  the  incision  one  small  vessel  is  severed, — the 
azygos  artery  of  the  vagina. 

It  requires  forcipressure  very  rarely,  being  an  insignifi- 
cant vessel.  Having  en- 

„'' --..^  tered  the  pelvic  cavity 

^  a  gauze  pad,  to  which 

N  a  string  is  attached,  is 

introduced.     While  the 

•^  ^-^^  ^^^^^^3*^   ,'''  "^    operator     washes      his 

hands,  an  assistant  low- 

FlG.  so. — 1-2,  The  anterior  incision,  used  CrS    the     table     mto    the 

when    hysterectomy    is    to    be   performed.  Trendelenburg  pOSition. 

3-4,  The  posterior  incision,  employed  when  a                       <.            <.f      1      j 

the  pelvic  contents  are  to  be  examined  and  ■^'-  oncC    all  unattacuecl 

the  viscera  treated  conservatively.  viscera  leave  the  pelvis. 

The  operator  now  in- 
serts his  two  index  fingers  into  the  rent,  and  upon  separat- 
ing his  hands  the  incision  is  spread  laterally  (Fig.  52).  This 
tear  takes  place  in  the  line  of  the  incision.  A  careful  digi- 
tal examination  is  now  made  of  the  pelvic  contents.  The 
finger  glides  up  along  the  smooth  posterior  uterine  wall 
as  high  as  the  fundus  and  is  then  swept  laterally  over 
one  cornu  and  tube.  The  ovary  and  tube  upon  one  side 
are  carefully  palpated.  If  tender  adhesions  are  met  with, 
they  are  torn  with  the  finger.  Unless  pus  is  suspected, 
the  effort  is  made  to  free  the  ovary  and  tube  from  adven- 
titious union.  The  operator  remembers  that  his  finger 
has  entered  bclozv  the  plane  of  the  bases  of  the  broad 
ligaments,  and  that  his  manipulations  are  behind  the 
broad  ligaments,  upon  their  posterior  surfaces.  At  once 
this  will  indicate  to  him  the  method  of  separating  adher- 
ent adnexa.  In  doing  this  the  finger  is  moved  between 
the  surfaces  of  union  from  the  side  of  the  uterus  upward 
and  outward,  a  sort  of  lifting  motion  being  made.  All 
the  time  the  adnexa  are  being  manipulated,  the  uterus  is 
firmly  held  down  with  the  bullet  forceps.  The  pelvis  is 
now  Aviped  free  from  blood.  If  firmly  adherent  adnexa, 
or  cystic  accumulations  are  met  with,  it  is  better  not  to 
complete  their  separation  before  inspecting  them.  In- 
spection of  the  pelvis  is  next  made.     A  medium   Pean 


Fig.  51. — Arterial  blood  supply  of  the  uterus  and  adnexa  :  O.  A.,  ovarian 
artery;  a' ,  a' ,  a',  branches  to  ampulla  of  Fallopian  tube  ;  r',  c'.  c' ,  branches 
to  ovary  ;  c,  branch  to  fundus  ;  d,  branch  anastomosing  with  uterine  ;  i,  branch 
to  round  ligament;  e,  uterine  artery ;  ^,  ^,  ^,  vaginal  arteries;  d,  b,  azygos 
artery  of  vagina. 


EXPLORATORY   VAGINAL   SECTION. 


141 


retractor  is  introduced  (Fig.  53),  and  the  perineum, 
vagina,  and  posterior  edge  of  the  incision  are  held  down 
by  it.  The  cervix  is  loosed  from  the  grasp  of  the  bullet 
forceps,  and  a  Pean-Pryor  trowel  is  inserted  behind  the 
uterus.  The  soiled  pad  is  now  removed,  and  several 
clean  ones  are  inserted.  The  uterus  is  pushed  up  behind 
the  symphysis  and  out  of  the  pelvic  cavity  by  the  trowel. 
This  is  the  very  essence  of  the  procedure,  for  by  it  the 


Fig.  52. — The  index  fingers  are  inserted  into  the  opening  in  the  cul-de-sac, 
and  tlie  incision  is  enlarged  by  blunt  tearing  with  the  fingers  (from  life). 

obstructing  uterus  is  lifted  out  of  the  way.  By  dexterous 
manipulation  of  the  trowel  the  adnexa  of  first  one  side 
and  then  the  other  are  exposed  to  view.  When  seen  they 
may  be  grasped  with  Luer's  forceps  and  brought  down 
into  the  vagina,  where  they  may  as  readily  be  operated 
upon  as  is  the  cervix  in  plastic  work  (Fig.  54). 


i4i 


PELVIC   INFLAMMATION. 


Pelvic  exostoses,  adherent  vermiform  appendix,  rectal 
cancer,  ectopic  gestation,  both  unruptured  and  ruptured, 
ovarian  cystoma,  ovarian  sarcoma,  uterine  fibroids,  hydro- 
salpinx, pyosalpinx,  cystic  and  apoplectic  ovaries,  occluded 
tubes,  dilated  ureters,  and  in  fact  every  form  of  pelvic 
disease  I  have  seen  are  most  of  them  treated  through 
such   an   incision.     By  relaxing  somewhat  the  perineal 


Fig.  53. — The  uterus  is  held  up  behind  the  symphysis  (5)  with  the  bladder 
{B)  by  the  trowel  (X),  while  the  rectum  {J?)  and  the  posterior  vaginal  wall 
are  pulled  down  by  the  retractor  (  V). 


retraction  and  forcibly  pushing  up  the  uterus  and  bladder 
the  ureters  are  made  tense  and  appear  as  curved  ridges 
beneath  the  lateral  pelvic  peritoneum.  The  space  gained 
between  the  trowel  and  retractor  is  nearly  that  made  by 
separating  the  fingers.  The  further  operative  treatment 
depends  upon  what  the  inspection  reveals.  Suffice  it  to 
say  that  I  pack  the  uterus  with  gauze,  remove  the  gauze 
pads,  insert  gauze  into  the  pelvic  opening  or  close  the 


EXPLORATORY   VAGINAL  SECTION. 


143 


opening  with  fine  silk,  and  replace  the  uterus.  The  cul- 
de-sac  is  entered^  in  two  minutes;  the  entire  procedure 
occupies  but  ten.  I  commonly  employ  a  partial  chloro- 
form narcosis,  as  complete  relaxation  is^not  necessary. 


Fig.  54. — The   adnexa  have   been   freed,  and   are   brought   down    into    the 
vagina.     Above  them  are  coils  of  intestine  (from  life). 

There  are  but  two  conditions  in  which  this  method  of 
exploration  is  not  a  completely  successful  one,  and  in 
them  the  indication  for  radical  operation  is  so  clear  that 


I  44 


PELVIC   INFLAMMATION. 


exploration  is  unnecessary.  I  refer  to  ectopic  gestation 
ruptured  into  the  broad  ligament,  and  to  intraligament- 
ous fibroid  tumors.  In  all  forms  of  adnexal  inflamma- 
tory disease  and  ovarian  neoplasms  I  have  found  it  emi- 
nently satisfactory. 

All  cavity  operations  are  in  their  first  stage  explora- 
tory, and  my  operation  occupies  that  position  with  regard 
to  future  work. 

I  will  contrast  the  abdominal  method  and  that  by  sec- 
tion in  front  of  the  uterus  with  my  operation.  In  abdomi- 
nal section  the  following  anatomical  layers  are  severed  : 
skin  (usually  infected),  fat,  fascia,  muscle,  and  peritoneum. 
In  anterior  colpotomy  (separating  the  bladder  from  the 
uterus)  the  vagina  is  severed,  the  tissues  uniting  the  blad- 
der and  cervix  (pericervical)  are  cut,  the  peritoneum  is 
cut.  In  my  operation  two  layers  are  severed,  the  vaginal 
wall  and  the  peritoneum. 

In  abdominal  section  many  small  vessels  are  cut  often 
requiring  ligation.  In  anterior  colpotomy  the  large 
branches  of  the  superior  vesical  and  uterine  arterial  anas- 
tomosis are  severed  and  require  ligature.  In  my  opera- 
tion no  vessel  needs  more  than  a  few  minutes  forcipres- 
sure.  After  laparotomy  a  number  of  sutures  are  required 
to  close  the  wound,  and  few  operators  are  agreed  how 
this  should  be  done. 

With  anterior  colpotomy  the  bladder  must  be  again 
sutured  to  the  uterus  by  a  complicated  method.  In  my 
operation  no  sutures  are  needed. 

There  is  little  danger  of  wounding  any  important 
structure  during  abdominal  section,  but  there  is  great 
danger  of  wounding  the  bladder  in  doing  anterior  col- 
potomy. There  is  no  possible  risk  run  in  my  operation 
of  wounding  any  organ,  as  the  finger  does  the  operating 
after  the  vaginal  mucosa  is  severed. 

Mural  abscess,  hernia,  inter-intestinal  adhesions,  and 
adhesions  between  the  scar  and  viscera,  result  often  from 
abdominal  section,  and  an  ugly  scar  is  left  as  a  reminder 
of  an  unpleasant  experience.  After  anterior  colpotomy 
the  uterus   is   held  low  in  the  pelvis  and  can  not  readily 


EXPLORATORY   VAGINAL   SECTION. 


145 


rise  because  of  thickening  in  the  pericervical  tissues. 
Hence  pregnancy  is  often  interrupted.  No  sequelae  fol- 
low my  operation,  and  the  uterus  is  not  limited  in  upward 
movement. 

The  entire  pelvic  contents  can  be  seen  by  abdominal 
incision ;  anterior  colpotomy  necessitates  pulling  the 
uterus  down  into  the  field  of  vision,  and  hence  nothing 
is  seen  until  dragged  into  the  vagina ;  the  whole  pelvis 
can  be  explored  by  means  of  rny  procedure.  Abdominal 
section  necessitates  a  profound  narcosis,  a  partial  one 
suffices  for  the  operation  I  advocate. 

To  sum  up,  abdominal  section  and  anterior  colpotomy 
inflict  needless  traumatism,  furnish  no  drainage  space, 
and  are  most  complicated  in  every  way,  while  my  opera- 
tion merely  requires  a  special  table  and  instruments  to 
be  simply  and  easily  done,  and  with  ample  drainage  space 
for  all  discharges. 

In  the  discussion  of  "  conservatism  "  diseased  organs 
will  be  mentioned  as  cured  without  removal  which  would 
have  been  sacrificed  had  laparotomy  or  anterior  col- 
potomy been  done. 

The  after  treatment  is  that  of  the  "  operation  for 
adherent  retropositions,"  which  see. 

If  this  method  of  inspecting  the  pelvis  accomplished 
nothing  else,  it  should  have  an  accepted  place  in  our 
procedures  as  a  means  of  clearing  the  diagnosis  of  a  sus- 
pected ectopic  gestation.  It  is  no  longer  necessary  to 
wait  for  symptoms  of  hemorrhage  and  exsanguination.  In 
three  minutes  or  less  the  diagnosis  can  be  made,  and  with 
no  risk.  A  special  table  is  not  necessary  for  ordinary 
vaginal  work.  One  may  be  improvised  which  will  give 
an  angle  of  60°  by  sawing  off  two  legs  of  a  stout  kitchen 
table.  The  shoulder  braces  can  be  arranged  by  boring 
two  rows  of  parallel  holes  down  the  centre  of  the  table 
into  which  pins  may  rest.  Against  these  the  shoulders 
may  be  supported,  or  assistants  m.ay  support  the  body 
while  in  position.     This  I  have  often  done. 


1^6  PELVIC   INFLAMMATION. 


CONSERVATIVE   TREATMENT. 

General  Considerations. — When  we  attack  diseased 
adnexa  either  through  the  abdomen  or  through  the 
vagina,  up  to  a  certain  stage  the  operation  is  in  all  cases 
exploratory:  for,  be  the  presumptive  evidence  what  it 
may  as  corroborative  of  the  diagnosis,  the  absolute  diag- 
nosis can  be  made  only  after  inspection  of  the  diseased 
structures.  When  operating  through  the  belly,  meeting 
with  a  hydrosalpinx  or  a  large  cystic  or  apoplectic  ovary, 
or  a  small  broad  ligament  cyst,  removal  seems  rather  too 
severe  for  the  pathological  lesions.  Still  it  would  appear 
unsafe  to  return  the  organs  after  evacuating  fluids  and 
inflicting  extensive  traumatism. 

So  long  as  pus  foci  only  are  removed  through  the 
abdomen,  without  drainage,  little  criticism  can  be  passed. 
Still,  even  pus  tubes  can  be  conservatively  treated  by 
another  method.  But  when  lesions  of  the  adnexa  are 
treated  by  extirpation,  which  lesions  by  no  possibility 
can  endanger  life,  not  only  the  operator,  but  his  art  as 
well,  is  brought  into  disrepute.  There  is  legitimate 
ground  for  debate  regarding  the  propriety  of  treating 
pus  foci  by  any  method  other  than  extirpation  through 
the  belly.  But  there  is  no  excuse  for  sacrificing  organs 
trivially  affected,  when  there  is  at  our  command  a  method 
difficult  to  be  sure,  but  perfectly  safe,  which  radically 
cures  and  yet  saves. 

But  local  conservatism  must  not  be  carried  too  far. 
There  is  a  broader  conservatism  which  seeks  the  preser- 
vation of  the  general  health  at  the  sacrifice  of  even  im- 
portant organs.  To  illustrate,  the  attempt  to  benefit  per- 
manently the  condition  of  a  woman  suffering  from  diffuse 
pelvic  suppuration  by  any  operation  other  than  the  most 
radical  is  absurd.  Equally  so  is  it  to  expect  conserva- 
tive surgery  of  any  sort  to  relieve  the  pains  of  genital 
sclerosis   affecting   uterus,   ovaries,  and  tubes.      I  cite 


CONSERVATIVE   TREATMENT. 


147 


these  two  extremes  to  demonstrate  the  necessity  for  a 
careful  differentiation  before  determining  upon  a  particu- 
lar operation, 

I  suppose  in  no  field  of  surgery  is  our  art  more  ham- 
pered, modified,  and  with  reason  influenced  by  the 
extraneous  circumstances  surrounding  the  patient.  A 
young  girl  of  nineteen  with  large  pus  tubes  is  of  course 
better  without  them.  But  to  check  the  new  function  of 
menstruation  at  its  inception  is  to  create  a  very  unhappy 
woman.  Therefore,  here  the  vaginal  conservative  opera- 
tion is  pre-eminently  indicated;  whereas,  in  a  woman  of 
forty,  with  children,  the  question  would  not  be  consid- 
ered except  as  bearing  upon  risk  to  life.  The  young 
woman  again  may  have  pus  tubes  due  to  an  abortion,  and 
be  phthisical.  No  matter  what  his  sentiments  and  desires, 
the  surgeon  will  be  governed  by  his  knowledge  of  the 
effects  upon  such  a  constitution  of  prolonged  suppura- 
tion, and  of  the  great  improvement  induced  in  the  gen- 
eral nutritive  functions  by  artificially  inducing  meno- 
pause.    Here  the  radical  operation  is  always  indicated. 

The  ability  to  determine  upon  the  proper  operation, 
whether  radical  or  conservative,  depends  upon  so  many 
factors  entering  into  the  surroundings  of  the  patient  and 
her  station  in  life,  the  equipments  of  the  operator  and 
the  place  in  which  he  works,  that  I  can  not  possibly  fore- 
see them  all.  The  statements  I  have  here  made  are 
occasionally  modified,  and  I  can  but  give  a  description 
of  my  usual  course  in  dealing  with  the  different  condi- 
tions. 

■  But  what  argument  can  be  offered  against  the  point  of 
view  of  the  conservative  man?  I  take  it,  none.  Then 
criticism  can  justly  lie  upon  his  results  only.  And  of 
these  I  will  now  speak. 

Thousands  of  cystic  ovaries  are  every  year  removed 
through  the  abdomen.  The  patient  may  be  hjgh-strung 
and  nervous.  She  has  pre-menstrual  pain  in  the  ovarian 
region ;  her  flow  is  scanty;  her  uterus  is  small  and  ante- 
flexed;  she  has  severe  pelvic  tenesmus;  she  is  hysterical 
and  is  given  to  introspection  and  self-pity;  she  never  has 


1^8  PELVIC   INFLAMMATION. 

fever;  the  ovaries  are  low  down  and  sensitive.  Com- 
monly, the  woman  is  in  advanced  maidenhood.  An 
operation  is  advised  and  accepted.  Upon  opening  the 
belly,  no  adhesions  are  found,  unless  intra-uterine  tinker- 
ing has  produced  peritonitis.  The  tubes  are  normal. 
The  ovaries  are  large  and  filled  with  cysts,  some  small, 
some  large.  The  ovarian  capsules  are  thick  and  tough. 
What  is  to  be  done  ?  To  enucleate  all  the  cysts  and 
suture  the  cut  surfaces  of  the  ovaries  is  eminently  proper. 
But  the  same  train  of  nervousness,  introspection,  regrets, 
remain,  only  now  she  has  a  belly-scar  to  study  twice  a 
day,  when  she  dresses  and  undresses.  This  she  will 
watch  carefully  for  hernia.  But  the  woman  is  not  physi- 
cally cured.  To  remove  the  ovaries  is  to  add  the  distress 
of  the  artificial  menopause  to  her  other  symptoms,  and 
make  her  still  more  hopeless.  Although  she  has  never 
expected  to  have  children,  she  is  now  relegated  to  the 
class  of  "  the  spayed."  This  picture  is  not  one  bit  over- 
drawn. 

Through  the  vagina  these  cystic  ovaries  can  be  success- 
fully treated,  cysts  emptied,  and  cut  surfaces  sutured  with 
perfect  safety,  no  possibility  of  hernia,  no  intestine  adhe- 
rent to  the  scar,  and  no  interintestinal  adhesions. 

The  lesions  existing  in  cystic  ovaries  never  require  re- 
moval of  the  organs.  Most  of  the  symptoms  accompany- 
ing them  are  due  to  other  conditions.  In  hydrosalpinx 
we  have  another  condition  productive  of  few  symptoms 
and  never  threatening  life.  To  open  the  belly  and  remove 
these  simple  cysts  of  retention,  is  to  perform  an  unneces- 
sarily severe  operation.  To  evacuate  them  through  the 
abdomen  and  leave  them,  is  to  undoubtedly  run  some 
risk.  Still,  evacuation  is  the  proper  operation  when  it  is 
done  through  the  vagina.  The  same  applies  to  ovarian 
apoplexy  and  small  broad  ligament  cysts,  to  occluded 
tubes  free  from  pus,  and  to  pelvic  adhesions.  The  great 
obstacle  heretofore  to  this  has  been  the  difficulty  inherent 
in  the  operations.  The  incision  and  posture  I  recommend 
render  the  operations  as  easy  when  done  through  the 
vagina  as  through  the  abdomen. 


CONSERVATIVE   TREATMENT. 


T49 


Coming  now  to  a  consideration  of  acutely  inflamed 
tubes,  my  task  is  more  difficult.  So  long  as  we  removed 
pus  tubes  and  ovaries  by  celiotomy,  our  work  was  emi- 
nently proper.  Those  were  the  cases  which  were  not 
checked  by  the  let-alone  treatment.  But  we  began  to 
remove  the  inflamed  adnexa  in  the  acute  stage,  before 
trying  any  other  measure.  There  we  made  a  mistake.  In 
many  of  these  cases  I  checked  the  infection  by  an  early 
curettage.  But  what  could  be  done  in  the  older  cases  ? 
It  is  useless  to  deny  to  organs  so  highly  vitalized  as  are 
the  ovaries  and  tubes,  great  power  of  recuperation  after 
infection.  The  size  of  the  arteries  supplying  them  proves 
that  this  possibility  exists.  It  has  not  heretofore  been 
taken  advantage  of,  because  not  understood.  The  acutely 
inflamed  tube  becomes  rapidly  occluded.  This  is  a  wise 
provision  of  Nature,  for  no  woman  could  live  if  a  con- 
tinuous stream  of  pus  was  poured  into  her  peritoneum. 
But  this  isolating  occlusion,  while  saving  life,  destroyed 
the  integrity  of  the  affected  tube ;  for  the  suppuration 
continuing  in  the  closed  tube  results  in  the  formation  of 
a  pyosalpinx. 

Naturally  the  question  is  suggested,  whether  this  occlu- 
sion would  occur  if  free  escape  of  the  tubal  nastiness  were 
possible.  In  other  words,  the  pathological  peritonitis  is 
beneficent,  in  that  it  saves  life,  but  it  is  unnecessary  where 
life  is  not  in  jeopardy.  And  where  unnecessary,  it  does 
not  occur.  Furthermore,  when  not  present,  because  relief 
from  the  infection  is  found,  the  vitality  of  the  affected  tube 
is  but  little  interfered  with,  and  its  power  of  repair  is 
vastly  greater  than  it  would  otherwise  be. 

Simply  expressed,  if  I  relieve  a  causative  endometritis 
by  curettage,  open  the  cul-de-sac,  and  open  and  drain  the 
resultant  acutely-inflamed  tube,  that  tube  will  get  well. 
Women  so  treated  have  recovered  symptomatically,  and 
their  pelves  have  become  free  from  appreciable  lesions. 
They  conceive  and  go  to  full  term.  I  can  not  do  this 
always,  because  I  cannot  always  accurately  measure  the 
extent  of  damage  done.  To  extirpate  an  acutely-inflamed 
tube  during  a  first  attack,  is  simply  to  deny  the  possibility 


i^o  TELVTC   INFLAMMATION. 

of  repair.  Still  we  have  all  seen  women  stupid  enough 
to  refuse  operation,  and  they  have  got  well  without  it. 
These  few  women  can  be  made  the  many  if  those  forces 
which  bring  recovery  to  the  few  are  appreciated  and  taken 
advantage  of. 

I  can  safely  say  that  pelvic  suppuration  can  be  pre- 
vented. The  rules  governing  these  operations  are  laid 
down  under  endometritis  and  salpingitis. 

No  man  nowadays  dare  assume  responsibility  for  the 
results  following  the  morphin-poultice-douche  treatment 
of  pelvic  inflammation.  As  surely  is  he  responsible  for 
the  hysterectoiny  which  will  some  day  be  the  result  of 
his  timidity,  as  he  will  be  for  a  death  from  the  neglected 
disease.  It  is  to  teach  how  to  prevoit  suppuration,  as 
well  as  how  to  cure  it,  that  I  have  .written  this  book. 

The  conditions  to  which  I  invariably  apply  conservative 
procedures  through  the  vagina  are :  hydrosalpinx,  whether 
unilateral  or  bilateral;  cystic  ovaries;  apoplexy  of  the 
ovary  ;  occluded  tubes  ;  small  h'oad  ligament  cysts,  single 
and  multilocular  ;  adherent  retropositions. 

The  conditions  to  which  I  generally  apply  conservative 
operations  are  :  Acute  pnrident  salpingitis  ;  acute  puerperal 
pelvic  lymphangitis  and  peritonitis ;  pyosalpinx  in  young 
women  when  seen  in  first  attacks  of  the  inflammation  ; 
recurrent  salpingitis. 

I  occasionally  do  a  palliative  operation  in  :  Diffuse  pel- 
vic suppuration ;  ovarian  abscess,  and  in  other  cases  of 
pelvic  suppuration  where  the  general  symptoms  are  too 
grave  to  warrant  an  immediate  ablation. 

The  conditions  in  which  I  generally  do  a  radical  opera- 
tion are  :  Diffuse  pelvic  S2ippuration  ;  genital  sclerosis  ;  go- 
norrheal pyosalpinx  in  women  over  thirty  ;  relapses  after 
conservative  operations ;  7itcrine  tubeirulosis ;  chroinc  me- 
tritis with  infected  ligatures  after  abdominal  operations 
upon  the  adnexa;  abdominal  sinus  left  after  celiotomy  for 
adnexal  disease;  ectopic  gestation  which  has  ruptured,  or 
unruptured  and  associated  with  adnexal  disease  on  the 
other  side ;  small  bilateral  ovarian  cystomata. 

Having  classified  my  cases  in  this  way,  I  may  state  that 


CONSERVATIVE   TREATMENT. 


151 


the  extraneous  circumstances  surrounding  my  patient 
often  compel  me  to  operate  in  the  face  of  what  my  judg- 
ment indicates  would  be  for  her  better  ultimate  interests. 
To  some  women  the  possession  of  even  badly  diseased 
organs  is  more  precious  than  health ;  and  to  others  the 
consciousness  that  they  have  lost  their  special  organs  is 
worse  than  death.  These,  I  know,  are  sentiments;  but  I 
believe  them  to  be  held  by  men  also.  Castration  is  an 
excellent  operation  for  hypertrophy  of  the  prostate,  but 
I  am  not  aware  that  it  is  received  philosophically  by  men, 
nor  often  allowed.  The  worst  that  can  be  said  of  con- 
servative operations  is  that  they  sometimes  fail  to  relieve. 
The  same  is  true  of  all  radical  work.  But  when  conser- 
vatism fails  the  patient  is  in  no  worse  state  than  before, 
and  radical  work  may  still  be  done. 

In  those  cases,  such  as  pronounced  suppuration,  where 
conservatism  does  not  succeed  in  affording  that  measure 
of  relief  expected,  at  least  the  operation  removes  the 
patient  from  the  class  of  emergency  operations  to  one  in 
which  the  radical  operation  can  be  made  elective.  That 
much  cannot  be  claimed  with  reason  to  attach  to  the 
primary  radical  operation. 

Failing  to  cure  by  a  conservative  procedure  applied  to 
a  pus  case,  the  necessary  mutilating  operation  can  later  be 
done  in  a  comparatively  clean  field,  with  the  kidneys  not 
taxed  to  eliminate  toxins,  with  the  bowel  functions  restored, 
with  the  heart  muscle  recovered,  and  altogether  with  the 
general  condition  most  propitious  to  a  successful  result. 
No  man  who  has  operated  in  the  stage  of  acute  infection 
with  breaking  down  of  the  tissues,  but  will  eagerly  grasp 
the  opportunity  to  convert  his  case  into  one  free  from  the 
disagreeable  and  dangerous  elements  attaching  to  the  first 
state.  Where  conservatism  does  not  succeed  in  curing, 
it  at  least  accomplishes  that. 


PELVIC   INFLAMMATION. 


CONSERVATIVE    OPERATIONS    UPON  THE    INFLAMED 
ADNEXA  UTERI. 

Acute  Salping-o-ooplioritis. — If  the  case  has  pro- 
gressed too  far  to  be  reheved  by  curettage  alone,  the 
efforts  of  the  surgeon  should  be  directed  to  the  preven- 
tion of  suppuration.  Up  to  recent  years  two  lines  of  pro- 
cedure were  open  to  us  :  either  to  let  the  case  alone,  or 
else  to  remove  the  diseased  adnexa.  Let  us  consider  a 
case  in  its  early  stages  before  suppuration  has  begun. 
The  pelvic  peritoneum  in  its  efforts  to  limit  and  shut  in 
this  infection  throws  about  the  adnexa  a  mass  of  lymph. 
This  is  a  beneficent  and  protective  act  and  is  usually 
effective.  Were  it  not  for  this  isolation  of  the  diseased 
organs,  it  is  to  be  presumed  that  a  general  and  fatal 
involvement  of  the  peritoneum  would  result.  But  at  the 
same  time  a  struggle  is  going  on  in  the  parts  inflamed, 
between  the  invadmg  germs  and  the  resistant  power  of 
the  tissues.  To  overcome  the  invasion,  either  a  suppur- 
ating, destructive  process  results,  or  else  a  connective 
tissue  hyperplasia  follows.  Either  destroys,  partially  at 
least,  the  functions  of  the  organs  involved.  Is  it  not  pos- 
sible to  check  these  processes  somewhere  ?  It  has  been 
determined  that  removing  the  causative  focus  and  drain- 
ing the  uterine  ends  of  the  tubes  and  lymph  streams  by 
curettage  is  not  sufficient  to  restore  the  diseased  adnexa 
to- a  condition  approaching  the  normal.  We  must  go 
outside  the  uterus  and  drain.  Whereas  we  consider  the 
effusion  of  lymph  and  the  production  of  connective  tissue 
essential  in  the  natural  process,  they  are  still  destructive. 
Up  to  a  certain  stage  we  can  check  them  and  effect  a 
cure.  It  is  in  the  very  earliest  stage  of  the  adnexal  dis- 
ease that  we  can  do  this. 

Operation. — If  the  uterus  has  not  been  previously  cur- 
etted this  is  now  done  (see  curettage).  If  curettage  has 
been  done  some  days  before,  the  uterus  is  irrigated  with 
boric  acid  solution.     Upon  opening  the  posterior  cul-de- 


CONSERVATIVE  TREATMENT. 


153 


sac,  serum  and  lymph  flakes  escape.  The  finger  is 
inserted  into  the  cavity  behind  the  uterus,  and  proceed- 
ing toward  the  lateral  pelvic  walls  all  the  tender  lymph 
planes  are  easily  severed  by  the  finger.  The  tubes  are 
freed  from  their  attachments  to  broad  ligament  or  vis- 
cera and  gently  brought  to  the  vaginal  vault  for  inspec- 
tion. It  is  not  a  difficult  matter  to  open  the  fimbriated 
ends  with  any  blunt  instrument,  the  tubes  being  held  by 
Luer's  forceps.  A  strip  of  iodoform  gauze  is  inserted 
into  the  tube  to  the  uterus.  This  is  left  in  place  until 
the  operation  is  over.  A  small  amount  of  fluid  may 
escape  from  the  tubes,  clear  or  cloudy.  It  is  now  pro- 
per to  wipe  the  pelvis  dry.  The  ovaries  are  palpated  and 
loosened  from  adhesions.  The  operator  makes  his 
investigation  of  the  broadest  kind.  No  false  attach- 
ments between  the  organs  should  be  overlooked.  Every 
lymph  plane  should  be  entered  and  broken  up.  Convinced 
that  the  tubes  are  opened  and  that  no  organs  have  been  left 
matted  together,  the  gauze  pads  are  removed,  the  pelvis 
is  carefully  wiped  dry,  and  the  strip  of  gauze  in  the  tube  is 
withdrawn.  The  uterus  is  packed  with  iodoform  gauze. 
Into  the  opening  in  the  cul-de-sac  strips  of  iodoform 
gauze  are  inserted  so  as  to  snugly  fill  the  opening. 
These  extend  up  behind  the  uterus  to  the  level  of  the 
internal  os.  The  uterus  and  dressings  are  lifted  up  into 
their  normal  position  in  the  pelvis,  and  the  vagina  is 
packed  with  gauze.  In  two  days  the  vaginal  and  uterine 
packings  are  removed  and  the  vagina  "again  packed. 
The  cul-de-sac  dressing  can  usually  remain  for  a  week. 
It  is  then  removed  and  renewed,  sometimes  under 
chloroform.  The  dressings  are  renewed  about  once 
in  five  days  until  the  wound  closes.  The  opera- 
tor seeks  to  open  the  lymph  streams  and  tubes  so 
as  to  cause  them  to  leak.  This  he  would  not  dare  do 
had  he  not  provided  through  his  gauze  a  means  of 
escape  for  the  discharges.  There  no  longer  being  a 
necessity  for  locking-in  infection,  the  tissues  do  not 
attempt  it.  The  curetting  having  cut  short  the  source 
of  infection,  no  fresh  supply  is  furnished.     The  causative 


,-^  PELVIC   INFLAMMATION. 

focus  in  the  uterus  is  removed,  and  the  comphcations  are 
attacked  by  evacuation.  The  question  is  suggested, 
Does  not  lymph  form  about  the  gauze  in  the  cul-de-sac  ? 
Undoubtedly ;  but  I  wish  to  call  attention  to  the  differ- 
ence between  the  character  of  the  lymph  which  forms 
about  an  absorbent  antiseptic  dressing  and  that  which  is 
the  exponent  of  infection.  The  first  is  not  accompanied 
by  pain,  by  fever,  nor  by  pus;  it  is  evanescent  and  pro- 
duces but  (qw  bands  of  adhesions  and  these  not  perma- 
nent. Furthermore,  it  is  limited  to  the  cul-de-sac  and 
does  not  implicate  the  tubes.  Lymph  the  result  of 
infection  is  absolutely  different.  Its  production  is  accom- 
panied by  fever,  by  occlusion  of  the  tube,  by  thickening 
of  the  ovarian  capsule,  by  great  pain;  and  it  is  permanent 
or  else  results  in  the  stoutest  kind  of  adhesions.  More- 
over, it  is  extensive  in  its  distribution.  The  operation  is 
the  counterpart  of  another  where  the  infected  focus  is 
cleaned  out  and  the  limb  above  incised  to  allow  of  escape 
of  the  products  of  the  results  of  the  progressing  infection, 
as  in  cellular  infection  of  the  hand  and  arm.  In  very 
many  cases  I  have  done  this  operation,  and  never  have  I 
failed  to  check  the  process.  The  operation  goes  a  step 
further  than  curettage.  It  is  not  only  conservative,  but 
is  curative.  To  deny  it  to  the  woman  is  to  refuse  to 
believe  that  her  most  highly  vitalized  organs  have  power 
of  repair  when  aided  by  incision  and  drainage.  It  is 
absurd  to  state,  as  some  do,  that  there  is  nothing  between 
the  let-alone  policy  of  the  midwife,  and  the  mutilating 
operation.  From  the  moment  the  adnexa  are  attacked 
by  infection,  evacuation  and  drainage  govern  us.  This 
operation  becomes  in  the  hands  of  the  practitioner  the 
means  by  which  he  prevents  suppuration,  and  by  apply- 
ing it  early  he  cures  his  cases  permanently.  It  certainly 
takes  some  courage  to  come  from  behind  the  protection 
of  the  hypodermic  syringe  and  thrust  oneself  into  the 
position  of  responsibility  for  the  result.  Morphin,  the 
poultice,  and  hot  douche  but  lull  the  patient  into  a  state 
of  insensibility  to  her  danger.  To  apply  these  is  to  do 
nothing ;  to  replace  them  with  this  operation  is  to  speed- 


CONSERVATIVE   TREATMENT. 


155 


ily  and  permanently  cure  these  patients.  Not  the  least 
attractive  attribute  of  the  operation  is  theease  with  which 
it  may  be  done.     It  is  entirely  free  from  danger. 

Clirouic  Salping^o-ooplioritis. — In  case  the  disease 
has  progressed  beyond  this  first  stage  of  cellular  infiltra- 
tion and  there  has  been  a  production  of  pus,  the  treat- 
ment is  different.  It  matters  not  whether  the  pus  be  in 
the  tubes  or  ovaries.  The  uterus,  unless  previously  cu- 
retted, is  cleaned  out  by  curettage  and  irrigation.  The 
patient  is  placed  in  the  lithotomy  position.  Upon  open- 
ing the  cul-de-sac,  the  operator  cautiously  works  his  finger 
up  behind  the  uterus.  When  he  has  reached  the  fundus, 
and  while  doing  this  he  makes  firm  down-traction  by 
means  of  blunt  bullet-forceps  hooked  into  the  cervix,  he 
carefully  determines  the  contour  of  the  ovaries  and  tubes. 
When  sufficient  space  has  been  secured  above  the  diseased 
adnexa,  gauze  pads  secured  by  strings  are  gently  inserted 
above  them.  If  a  pus-sac  is  found  low  down,  it  is  opened 
by  inserting  a  closed  pair  of  blunt  scissors.  As  the  pus 
escapes  the  scissors  are  opened  and  withdrawn,  thus 
making  a  broad  rent.  A  finger  is  now  inserted  into  the 
opening,  and  the  whole  interior  of  the  cavity  is  explored. 
All  pouches  are  entered  and  the  pus  evacuated.  After 
the  flow  of  pus  ceases,  the  edges  of  the  sac  are  grasped 
with  Luer's  forceps  and  held  apart,  while  the  operator 
temporarily  packs  the  sac  with  iodoform  gauze.  The 
pelvis  and  vagina  are  wiped  dry,  and  after  cleansing  his 
hands  the  operator  seeks  possible  foci  in  the  other  ovary 
or  tube.  When  found  these  are  similarly  treated.  After 
cleaning  out  all  the  pus  sacs,  the  field  of  operation  is 
thoroughly  sponged.  Under  no  conditions  should  the 
pelvis  be  irrigated,  lest  pus  be  washed  up  into  the  higher 
cavity.  It  is  not  advisable  to  sever  the  adhesions  above 
the  diseased  organs.  The  isolating  dome  of  lymph 
which  usually  exists  at  the  pelvic  brim  is  to  be  left  undis- 
turbed. So  far  the  operation  has  been  one  of  evacuation 
only.  By  means  of  the  dressings  to  be  applied  the  oper- 
ator seeks  the  obliteration,  by  production  of  connective 
tissue,  of  the  affected  cavity.   The  gauze  pads  are  removed. 


T56 


PET,VIC   INFLAMMATION. 


Molding  open  the  pus-sacs,  each  is  filled  with  iodoform 
gauze,  the  ends  of  which  project  into  the  vagina.  After 
this  the  pelvis  itself  is  tightly  packed  with  the  same  dress- 
ing. The  uterus  is  now  packed  with  gauze.  No  attempt 
at  replacement  is  made,  but  the  organs  are  left  in  the  posi- 
tion in  which  they  are  found.  The  vagina  is  packed. 
The  uterine  packing  is  removed  in  two  days.  At  the  first 
general  dressing  in  a  week  chloroform  is  given.  As  the 
gauze  is  removed  from  each  pocket,  it  is  renewed  before 
other  pieces  are  taken  out.  After  all  packings  in  the  pus 
sacs  are  removed  and  replaced  by  fresh  dressing,  the 
gauze  in  the  pelvis  is  renewed.  Future  dressings  are 
made  every  four  days  until  the  openings  close.  The 
operation  leaves  the  organs  in  a  damaged  state.  These 
women  are  sometimes  cured  of  all  symptoms,  but  com- 
monly they  have  some  pelvic  pain.  They  menstruate, 
but  are  sterile  when  the  adnexa  of  both  sides  have  been 
involved.  In  the  course  of  time  the  tube  or  ovary  so 
treated  becomes  a  mere  mass  of  connective  tissue.  The 
case  assumes  the  characteristics  of  genital  sclerosis,  and 
the  after-treatment  is  that  of  sclerosis.  Before  the  scle- 
rosis becomes  complete,  another  infection  may  set  up 
suppuration  again ;  but  where  both  ovaries  and  tubes 
have  been  treated  in  this  way  and  have  become  finally 
obliterated,  I  have  not  seen  suppuration  occur. 

Pus  formation  is  not  to  be  expected  in  tissues  sclerosed 
by  connective  tissue.  In  no  sense  does  this  operation 
resemble  the  old  puncture  by  means  of  trocar.  When 
the  trocar  showed  pus,  it  did  not  thoroughly  evacuate  it, 
and  no  protection  was  afforded  against  future  suppuration. 
If  the  trocar  failed  to  find  pus,  it  was  not  evidence  that 
pus  did  not  exist.  The  trocar  puncture  was  a  blind  pro- 
cedure, and  the  trocar  entered  all  tissues  lying  in  its 
path.  The  operation  described  is  safe,  thorough,  and 
essentially  scientific. 

Should  a  patient  so  treated,  at  some  subsequent  time 
again  become  infected,  with  the  production  of  pus  in  the 
pelvis,  an  immediate  evacuation  or  the  radical  operation 
is  indicated.     The  urgency  in  the  indication  lies  in  the 


CONSERVATIVE   TREATMENT. 


157 


fact  that  the  organs  no  longer  have  unbroken  walls,  and 
hence  pus  soon  tears  through  into  the  general  pelvic 
cavity. 

Repeated  bacteriological  examinations  have  shown  that 
no  matter  what  the  cause  of  the  suppuration,  after  a  few 
dressings  the  field  of  operation  is  sterilized.  No  pyo- 
genic cocci  are  found,  but  the  colon  bacillus  is  very  con- 
stantly present.  All  that  is  apparently  necessary  to  in- 
duce the  presence  of  this  germ  is  any  traumatism  inflicted 
upon  the  vagina  or  retro-uterine  structures. 

Chronic  Lesions. — Hydrosalpinx. — These  simple  cysts 
of  retention  have  heretofore  been  treated  by  removal 
through  the  abdomen.  As  early  as  1891  I  became  con- 
vinced that  they  were  inocuous,  but  up  to  five  years  ago 
had  not  attempted  their  treatment  through  the  vagina. 
The  fluid  they  contain  is  very  generally  sterile  serum,  and 
its  evacuation  into  the  pelvis  produces  no  more  reaction 
than  the  presence  of  peritoneal  fluid.  No  tube  the  seat 
of  hydrosalpinx  should  ever  be  sacrificed. 

Operation. — The  cul-de-sac  is  opened  after  curettage 
of  the  uterus.  The  uterus  is  held  down  by  the  traction 
forceps,  and  the  affected  tube  is  easily  freed.  When  it  is 
exposed,  with  a  blunt  pair  of  scissors  it  is  incised  for  an 
inch  along  its  upper  border,  beginning  at  the  fimbriated 
end.  The  fluid  is  caught  with  gauze  as  it  escapes,  and 
the  pelvis  is  wiped  dry.  But  little  oozing  takes  place  un- 
less many  adhesions  have  been  severed.  Unless  an  indi- 
cation exists  for  draining  the  pelvis,  the  incision  in  the 
vagina  is  sutured  by  a  continuous  suture  of  chromic  cat- 
gut, and  the  uterus  is  packed  with  iodoform  gauze.  It  is 
then  replaced  and  the  vagina  tamponed  with  iodoform 
gauze.  The  uterine  packing  is  removed  in  two  days  and 
the  vaginal  dressing  renewed.  The  patient  is  allowed 
out  of  bed  on  the  tenth  day,  the  vagina  being  kept 
tamponed  until  it  is  entirely  healed  and  until  the  sutures 
have  become  absorbed.  This  latter  occurs  in  about  two 
weeks.  Whenever  the  operator  is  in  doubt  regarding 
the  propriety  of  closing  the  vaginal  incision,  it  may  be 
kept  open  by  a  packing  of  gauze.     The  convalescence  is 


158 


PELVIC  INFLAMMATION. 


afebrile  and  the  recovery  complete.  Sometimes  the  walls 
of  an  old  hydrosalpinx  are  thick  and  ooze  when  incised. 
Beginning  at  the  fimbriated  end  of  one  side  of  the  cut  a 
running  suture  of  fine  catgut  is  taken  down  one  side  of 
the  cut  to  the  angle  of  the  incision  in  the  tube,  and  then 
along  the  other  side  to  the  fimbriated  end.  In  this  way 
the  peritoneum  of  the  incision  is  folded  over  to  the  lining 
membrane  of  the  tube  (Fig.  55).    Oozing  is  thus  checked 


"'^. 


Fu;.  55. — Salpingostomy.  The  occluded  tube  has  been  incised  along  its 
upper  border,  and  a  running  suture  is  being  taken  so  as  to  bring  the  mucous 
lining  to  the  serous  covering  of  the  tube,  and  in  this  way  maintain  the  tube's 
patency. 

and  closure  of  the  tube  prevented,  "salpingostomy." 
The  cul-de-sac  is  not  closed  in  such  a  case,  but  is  packed 
lightly  with  gauze.  In  all  hydrosalpinx  cases  the  uterus 
if  retroverted  is  replaced. 

Cystic  Ovaries. — These  should  never  be  removed. 
They  produce  but  little  pain  and  cause  only  mild  reflex 
symptoms.     The  uterus  is  curetted  and  the  cul-de-sac 


CONSERVATIVE   TREATMENT.  159 

opened.  The  ovary  is  freed  from  false  adhesions  and 
brought  down  into  the  vagina;  where  it  is  held  by  bullet 
forceps.  One  by  one  the  cysts  are  stabbed  with  a  ten- 
otomy knife.  Sometimes  a  cyst  is  met  with  of  large 
size,  even  one  inch  in  diameter.  It  is  to  be  evacuated, 
its  edges  are  trimmed,  and  the  membrane  which  usually 
lines  it  is  peeled  out.  The  cut  edges  are  then  brought 
together  by  a  running  suture  of  fine  chromic  catgut. 

After  all  cysts  are  emptied  the  ovary  will  be  found 
much  shrunk.  (See  Fig.  32.)  It  is  returned  to  the  pel- 
vis, and  the  vaginal  incision  closed  or  packed  as  indi- 
cated. The  uterus  is  packed  with  iodoform  gauze  and 
replaced  by  a  vaginal  tamponade  of  the  same  material. 
The  after-treatment  is  the  same  as  for  hydrosalpinx. 

Ovarian  Apoplexy. — The  uterus  is  curetted  and  the 
cul-de-sac  opened.  The  ovary  is  freed  and  pulled  into 
the  vagina  with  bullet  forceps.  While  held  there  the 
blood  cyst  is  incised,  and  the  contained  clot  evacuated. 
The  edges  of  the  cyst  are  trimmed  with  scissors,  and 
then  the  lining  of  the  sac  is  peeled  out  with  Luer's  or 
other  suitable  forceps.  After  this  is  done  it  will  be  found 
that  the  ovary  is  much  reduced  in  size.  If  the  resultant 
cavity  is  large,  I  trim  it  so  as  to  form  two  thick  flaps 
which  I  suture  readily  with  a  running  suture  of  fine  silk 
or  chromic  catgut.  I  prefer  the  latter.  If  the  cavity  is 
small,  I  leave  it  open  and  do  not  bother  to  sew  it.  It 
may  ooze  a  little,  but  no  more  than  would  a  ruptured 
Graafian  follicle. 

I  usually  leave  the  vagina  open  in  these  cases  and 
pack  with  gauze,  because  these  cysts  are  prone  to  be  of 
remote  septic  origin.  The  uterus  is  packed  with  gauze 
as  also  is  the  vagina.  The  after-treatment  is  similar  to 
that  of  other  non-suppurating  cases. 

Adherent  Ovaries  and  Occluded  Tubes.  —  The 
uterus  is  curetted  and  the  cul-de-sac  opened.  All  adhe- 
sions are  broken  with  the  fingers  or  else  held  up  with  a 
blunt  hook  and  severed  with  scissors.  The  occluded 
tube  is  drawn  into  the  vagina  and  incised  along  its 
superior  border   for   an   inch    from   its  fimbriated  end. 


l6o  PELVIC   INFLAxMMATiUN. 

Thefimbrije  are  teased  apart  with  forceps.  While  hold- 
ing apart  the  edges  of  the  V-shaped  cut,  a  running 
suture  of  fine  catgut  is  taken  from  the  upper  border  of 
the  fimbriae  down  to  the  angle  and  up  to  the  fimbriae  of 
the  lower  flap.  (See  Fig.  55.)  This  suture  is  so  applied 
as  to  unite  the  peritoneal  surface  with  the  lining  of  the 
tube,  and  is  used  for  the  purpose  of  preventing  closure 
of  the  tube.  The  uterus  is  packed,  and  the  opening  in 
the  cul-de-sac  filled  with  gauze  which  reaches  just  within 
the  cut  edges.  The  vagina  is  packed  with  gauze.  The 
usual  after-treatment  is  employed. 

Broad  Ligament  Cysts. — When  these  are  purely 
pelvic,  whether  single  or  multiple,  they  can  be  treated 
through  the  vagina.  When  they  reach  up  to  the  pelvic 
brim  they  should  be  removed  by  laparotomy. 

The  uterus  is  curetted  and  the  cul-de-sac  opened.  At 
once  the  smooth  thin-walled  cyst  is  felt.  It  has  no  pedi- 
cle; therefore,  the  uterus  is  held  up  with  a  trowel  while 
the  posterior  vaginal  wall  is  drawn  down.  Gauze  pads 
are  inserted  above  the  cyst  and  the  intestines  kept  up. 
With  blunt  scissors  the  cyst  is  split  open  and  emptied. 
A  portion  of  the  flaccid  posterior  walls  of  the  cyst  is  torn 
away  with  Luer's  forceps.  The  pelvis  is  wiped  dry,  and 
the  pads  removed.  No  bleeding  of  consequence  results. 
The  uterus  is  packed  with  gauze,  the  cul-de-sac  is  filled 
with  the  same  material  which  reaches  up  to  lower  margin 
of  the  cyst  cavity,  and  the  vagina  is  packed.  The  usual 
after-treatment  is  employed. 

The  After-Treatmeiit  in  Non-Purulent  Cases. — In 
two  days  the  vaginal  dressings  are  removed  and  the  uter- 
ine packing  withdrawn.  The  vagina  is  again  packed. 
From  eight  to  ten  days  after  the  operation  the  patient 
is  placed  in  Sim's  position  and  the  cul-de-sac  dress- 
ing taken  out.  In  doing  this  the  uterus  must  be  sup- 
ported by  the  trowel.  Fresh  dressing  is  inserted  and  the 
vagina  again  packed. 

The  second  dressing  is  made  in  a  week  more,  after 
which  the  patient  is  allowed  up.  The  cul-de-sac  is  kept 
packed  until  closed. 


PREPARATION    FOR   A    VAGINAL   SECTION.         i6i 

If  the  vaginal  incision  has  been  sutured,  the  sutures 
are  removed  in  two  weeks,  and  the  vagina  kept  packed 
until  the  scar  is  stout. 

I  do  not  give  douches  until  the  wound  is  healed,  and 
forbid  intercourse  for  six  weeks  after  the  patient  is  dis- 
cha'rgfed. 


PREPARATION    OF    PATIENT   FOR   A 
VAGINAL  SECTION. 

General. — The  presence  of  nephritis,  of  cardiac  dis- 
ease, or  of  phthisis  is  no  bar  to  the  operation.  Where 
patients  have  influenza  I  prefer  waiting  for  a  few  days 
until  this  subsides,  lest  the  narcosis  excite  a  broncho- 
pneumonia. Five  days  before  the  operation  the  patient 
is  given  a  calomel  purge.  I  prefer  triturates  of  calomel 
each  of  gr.  ^,  given  at  7,  8,  9,  and  10  p.m.,  to  be 
followed  next  morning  by  a  saline  purge,  like  Seidlitz 
powder.  The  diet  is  general  and  includes  everything 
but  the  more  indigestible  foods  and  luxuries.  I  exclude 
everything  fried,  whether  vegetable  or  flesh;  stimulants 
are  withdrawn,  and  narcotics,  if  previously  used,  are  not 
allowed.  The  patient  is  made  to  lie  down  most  of  the 
time,  reading  periodicals,  seeing  few  friends,  and  alto- 
gether assuming  a  semi-invalid  state.  She  is  encouraged 
to  drink  large  quantities  of  water.  Each  night  she  is 
given  a  high  enema  of  normal  salt  solution,  of  two  pints. 
This  she  is  encouraged  to  retain.  The  object  is  to  charge 
the  tissues  with  fluid.  This  has  been  shown  not  only  to 
actually  increase  the  amount  of  urine,  but  also  to  facilitate 
the  elimination  of  urea.  I  have  the  urine  analyzed  for 
sugar,  albumen,  and  per  cent,  of  urea,  the  total  for 
twenty-four  hours  being  carefully  measured.  If  fever  has 
existed  before  this  treatment  is  instituted,  it  usually 
diminishes,  and  if  there  is  albumen  in  the  urine  this 
decreases.  I  strive  to  get  the  emunctories  cleansed  out 
and  at  the  same  time  store  up  an  excess  of  fluid  for  the 
day  following  the  operation,  when  the  kidneys  take  away 


x62  PELVIC   INFLAMMATION. 

at  least  from  half  a  quart  to  a  quart  of  urine  and  no  fluids 
are  invested.  The  shock,  both  surg^ical  from  hemor- 
rhage,  and  vasomotor  from  traumatism  to  these  impor- 
tant pelvic  structures,  is  much  diminished. 

Local. — Two  days  before  operating  I  prepare  the 
patient.  The  pubes  and  vulva  are  shaved,  the  abdomen 
is  covered  by  a  wet  dressing  of  ^^  per  cent,  lysol  solu- 
tion, and  the  vagina  is  packed  with  gauze  wet  in  bichlorid 
solution  j^Vff.  These  dressings  are  changed  twice  more 
before  the  operation.  The  day  before  operating  I  give 
meat  once,  potatoes,  bacon,  eggs,  tea,  soup,  as  much  as 
needed.  All  the  time  the  patient  is  instructed  to  drink 
two  quarts  of  water  a  day.  I  do  not  like  milk.  In  the 
first  place  it  has  poor  food  value  for  an  adult,  and  its 
digestion  results  in  the  formation  of  "  bullets  "  in  the 
bowels.  Furthermore,  the  intestinal  gases  are  increased 
by  it.     For  the.  same  reason  I  do  not  use  koumyss. 

After  the  first  purge  of  calomel  and  salts,  it  is  rarely 
necessary  to  use  another  laxative;  but  if  needed,  one  pil. 
rhei.  comp.  may  be  given  two  days  before  operating. 

The  day  I  operate  I  give  no  food  or  drink  after  mid- 
night, if  the  narcosis  is  to  be  in  the  forenoon.  If  I 
operate  in  the  afternoon,  I  give  coffee  and  toast  for 
breakfast  and  a  pint  of  water  at  1 1  a.  m.  I  do  not  give 
stimulants  either  before  or  during  the  operation.  Cer- 
tain very  desperate  cases  are  met  with:  those  with 
nephritis  and  prolonged  suppuration.  In  such  cases  I 
perform  transfusion  into  the  elbow  vein,  using  c.  p.  nor- 
mal salt  solution,  and  introducing  as  much  as  sixteen  to 
sixty  ounces  at  the  time  of  operating.  To  old  drunkards 
and  to  women  with  fatty  hearts,  I  sometimes  give  a 
hypodermic  of  strychnia,  gr.  ^V,  before  beginning  the 
narcotic.     But  I  do  not  do  this  often. 

Cleaiising-  the  Patient. — The  position  is  that  for 
lithotomy,  with  the  coccyx  hanging  over  the  table. 
The  thighs  and  vulva  are  scrubbed  with  lysol  solu- 
tion 2  per  cent.  The  packing  is  withdrawn  from  the 
vagina,  and  the  latter  is  scrubbed  with  i  per  cent,  lysol 
solution,  using  for  this  purpose  a  long  brush  (jeweller's, 


VAGINAL  ABLATION. 


163 


(Fig.  56).  The  perineum  is  depressed  and  the  brush 
moved  up  and  down  and  rotated  within  the  vagina  while 
an  assistant  pours   the   solution  into  the  vagina.     After 


JOUN  KEYNDKRS—CO.    NJiW    yuciK. '^ 

Fig.  56. — Brusli  for  scruljbing  tlie  vagina. 

using  the  lysol  the  external  parts  and  vagina  are  scrubbed 
gently  with  Thiersch  solution.  The  legs  and  all  parts 
of  the  field  of  operation  are  covered  by  sterilized  towels 
or  stockings.     The  operator  then  proceeds. 


VAGINAL  ABLATION/ 

General  Cousidei'ation^. — The  vaginal  mucosa  and 
peritoneum  only  are  severed  in  vaginal  hysterectomy; 
whereas,  in  laparotomy,  the  skin,  fat,  fascia,  muscle  and 
peritoneum  are  cut.  In  vaginal  hysterectomy  no  vessels 
are  cut  by  the  incisions  which  require  ligation,  but  many 
small  arterial  trunks  must  often  be  secured  in  making  an 
abdominal  wound.  It  is  not  necessary  to  sever  the  peri- 
toneum in  performing  vaginal  ablation,  for  sufficient  space 
may  be  secured  without  that.  It  is  necessary  to  dissect 
the  uterus  from  the  bladder  in  both  vaginal  and  abdomi- 
nal ablation,  but  in  the  former  the  advantage  is  present 
of  having  the  cervix  as  a  guide.  The  uterus  and  adnexa 
to  be  removed  are  not  masked  by  the  viscera  which  lie 
above  them  when  vaginal  ablation  is  done. 

Separation  of  Adhesions. — It  is  usually  necessary  to 
work  through  a  mass  of  adherent  intestines  before  the 
organs  we  seek  are  seen  in  laparotomy,  while  the  work 
in  vaginal  ablation  proceeds  below  the  matted  intestines 
which  lie  above  the  uterus.  This  attribute  of  the  vaginal 
operation  is  worthy  of  a  moment's  discussion.  We  find 
two    kinds    of   adhesions :    Those    which    have    formed 


164 


PELVIC   INFLAMMATION. 


between  the  various  coils  of  intestine,  the  intcr-intcstinal ; 
and  those  which  exist  between  the  organs  to  be  sacri- 
ficed and  the  intestines.  We  do  not  disturb  the  inter- 
intestinal  adhesions  at  all  when  we  perform  vaginal  abla- 
tion. The  point  may  be  raised  that  it  is  advisable  to 
dissect  the  intestines  free ;  but  the  weight  of  opinion 
is  in  support  of  the  belief  that  when  this  is  done,  not 
only  do  the  adhesions  re-form,  but  that  the  secondary 
union  is  more  general  when  we  deal  with  pus  cases, 
such  as  are  under  discussion.  Certainly  the  experience 
is  exceptional  with  all  of  us  to  find  upon  making  a  sec- 
ond laparotomy  that  there  are  not  evidences  throughout 
the  track  of  the  operation  of  a  pretty  general  infection 
resulting  from  the  first  section.  Furthermore,  in  per- 
forming even  a  primary  section  in  these  pus  cases,  the 
inter-intestinal  adhesions  are  so  firm  that  breaches  are 
made  in  the  intestinal  walls,  often  requiring  suture. 
Regarding  the  adhesions  between  the  uterus  and  the 
organs  to  be  removed,  whatever  raw  surfaces  are  made 
upon  the  intestines  in  the  vaginal  operation,  remain 
turned  down  toward  the  point  best  adapted  for  drainage ; 
whereas,  in  the  abdominal  operation  all  the  raw  surfaces 
are  dragged  up  above  the  pelvic  brim,  with  a  possibility 
of  infecting  all  points  from  which  manipulation  has 
removed  the  endothelium. 

In  the  vaginal  operation,  only  those  false  unions  are 
severed  which  bind  the  diseased  organs  to  be  removed, 
and  these  are  much  less  important  than  those  which  exist 
at  and  above  the  pelvic  brim. 

We  are  forced  to  the  conclusion  that  any  operation 
which,  other  attributes  being  about  equal,  will  furnish  an 
escape  from  the  tedious  dissection  often  incident  to  a 
laparotomy  in  pus  cases,  will  bestow  the  greatest  immun- 
ity from  one  most  disagreeable  sequela  of  laparotomy.  In 
abdominal  section  very  often  a  grave  intra-peritoneal 
operation  has  been  done  before  the  organs  sought  for  are 
even  seen.  Usually  the  uterus  and  adnexa  are  removed 
per  vaginain  without  a  knuckle  of  movable  intestine 
being-  seen. 


VAGINAL  ABLATION.  165 

Direction  of  Efl'oit  in  the  Eimcleatioii. — In  lapar- 
otomy the  operation  proceeds  through  an  incision  which 
is  expected  to  heal  by  first  intention  and  through  a  mass 
of  adherent  intestines.  The  infected  organs  are  dragged 
up  between  the  raw  surfaces  left  after  separating  the 
adherent  intestines  and  between  the  margins  of  the 
abdominal  incision.  The  fingers  whether  naked  or 
gloved  repeatedly  take  the  same  path,  and  no  hand 
which  has  been  engaged  in  liberating  and  removing 
pus  foci  can  be  insured  as  clean.  In  laparotomy  the 
organs  removed  are  dragged  from  their  pelvic  attach- 
ments through  the  lower  part  of  the  abdomen.  In  vagi- 
nal ablation  the  direction  of  the  effort  is  in  the  direction 
of  drainage  at  the  lowest  part  of  the  peritoneal  pouch. 
The  pelvic  filth  remains  pelvic  and  is  never  led  into  the 
abdomen.  It  does  not  pass  by  tissues  which  are  to  be 
sutured,  and  does  not  infect  areas  of  intestine  from  which 
the  endothelium  has  been  removed  by  manipulation. 

Hemostasis. — In  laparotomy  this  is  by  means  of  liga- 
tures which  must  be  absorbed ;  certainly  those  upon  the 
ovarian  vessels  are  cut  short  and  left  in.  These  ligatures 
are  so  frequently  infected,  being  placed  in  an  infected 
field,  that  they  are  often  sources  of  trouble  although 
isolated  in  a  mass  of  lymph.  All  the  problems  embraced 
in  a  consideration  of  the  choice  of  ligature  material,  its 
preparation  and  its  fate,  are  factors  when  the  operation  is 
done  through  the  abdomen.  They  are  not  considered 
in  the  vaginal  operation. 

Dralnag-e. — In  laparotomy  this  must  sometimes  be 
employed,  particularly  in  cases  of  streptococcus  infec- 
tion, diffuse  suppuration,  and  where  tubo-rectal  fistul^e 
exist.  As  a  result  the  isolation  of  the  area  drained  is 
effected  by  a  matted  mass  of  lymph  thrown  out  by  the 
intestines,  and  a  breach  is  left  in  the  abdominal  scar. 
Besides,  the  pelvic  filth  is  drained  through  the  normal 
abdominal  cavity,  and  is  up-hill.  In  vaginal  ablation  the 
drainage  is  always  used  ;  it  is  at  the  lowest  part  of  the 
pelvic  cavity;  the  intestines  do  not  become  adherent  to 
the  drain  or  area  drained,  the  pelvic  filth  remains  pelvic, 
and  drainage  is  down-hill. 


ir,6  PELVIC  INFLAMMATION. 

Drainage  after  laparotomy,  though  not  often  used 
now-a-days,  infects  tlie  entire  area  adjacent  to  the  drain 
from  the  pelvic  floor  to  the  abdominal  skin.  Drainage 
after  vaginal  ablation  passes  for  not  over  an  inch  through 
the  lowest  part  of  the  pelvic  peritoneum,  and  most  of  it 
is  through  the  vaginal  tube  which  is  particularly  adapted 
to  carry  off  the  material  drained  away  without  absorbing 
any.  The  infected  drainage  space  after  laparotomy  re- 
mains for  a  large  part  an  abdominal  complication,  and 
for  weeks. 

After  vaginal  ablation,  the  drainage  track  is  in  a  few 
hours  made  extraperitoneal  by  the  union  of  bladder  to 
rectum. 

Sutures. — These  are  not  used  in  vaginal  ablation.  So 
important  a  matter  is  the  method  by  which  the  abdomi- 
nal wound  should  be  closed  that  there  are  about  as 
many  varieties  as  there  are  operators.  Shall  the  wound 
be  closed  by  buried  catgut,  buried  kangaroo  tendon,  or 
buried  silver  wire  ?  Shall  the  wound  be  united  by 
suturing  in  tiers  or  through-and-through  suturing,  or 
shall  the  fat  be  left  open  ?  Shall  the  sutures  be  applied 
as  interrupted  or  mattress  or  continuous  sutures? 

Hei-nia. — The  percentage  of  hernias  after  laparotomy 
is  not  known,  but  there  are  many  of  them.  They  are  not 
known  to  follow  the  vaginal  ablation  by  forceps.  The 
intra-abdominal  effort  is  almost  wholly  borne  above  the 
symphysis,  while  the  vaginal  vault  is  protected  from  this 
force  by  the  posture  of  the  body  and  the  sacral  promon- 
tory. 

Accidents. — In  abdominal  hysterectomy  the  bowel 
must  sometimes  be  sutured;  the  ureters  have  been  cut; 
abdominal  fistulas  are  known  to  exist,  and  ligatures  have 
worked  their  way  into  the  bladder.  After  vaginal  abla- 
tion intestinal  suture  and  resection  must  be  exceedingly 
rare  procedures ;  in  the  few  cases  in  which  the  bladder 
has  been  wounded  the  rents  closed  without  suture,  un- 
less made  by  the  veriest  tyro;  no  wandering  ligatures  are 
heard  of,  and  no  abdominal  fistula  are  found. 

Instruments. — In  laparotomy  knives,  scissors,  needles, 


VAGINAL   ABLATION.  1 67 

sutures,  ligatures,  needle-holders,  etc.  In  vaginal  ablation 
no  needles,  no  sutures  and  no  ligatures.  Much  less  com- 
plicated is  the  preparation  for  vaginal  section. 

Narcosis  and  Time. — Abdominal  hysterectomy  ne- 
cessitates an  abdominal  section  and  a  hysterectomy. 
Vaginal  ablation  is  a  hysterectomy  only,  without  the 
abdominal  section.  Few  men  can  perform  2i  finished  2iQ- 
dominal  hysterectomy  in  less  than  three-quarters  of  an 
hour  in  pus  cases.  Twenty  minutes  only  need  be  con- 
sumed in  vaginal  ablation.  In  order  to  secure  relaxation 
of  the  abdominal  muscles  profound  narcosis  is  necessary 
in  laparotomy.  With  vaginal  ablation  the  narcosis  is  in- 
complete and  short,  and  chloroform  again  becomes  the 
preferable  anesthetic. 

Coiivalesceuce. — No  man  who  has  seen  a  number  of 
similar  cases  treated  by  the  two  methods  but  will  decide 
that  the  ability  to  turn  over  in  two  days,  the  assumption 
of  regular  diet  in  four  days,  the  regularity  of  the  bowels 
from  the  first,  the  absence  of  nausea  and  vomiting,  the 
early  getting-up,  make  the  convalescence  from  vaginal 
ablation  much  less  disagreeable  than  from  laparotomy. 

Results. — No  case  of  mine  has  died  either  from  the 
operation  or  from  complications.  There  are  no  fecal 
fistulas  to  report,  no  sinuses,  no  vesicovaginal  fistulae,  and 
no  hernias.  There  have  been  no  cases  of  phlebitis  and 
no  intestinal  obstructions.  The  vagina  has  in  no  case 
been  shortened,  and  intercourse  is  painless. 

These  are  the  reasons  why  I  perform  vaginal  ablation 
in  pus  cases. 

Having  stated  my  reasons  for  preferring  the  vaginal 
route,  I  may  properly  mention  what  cases  I  exclude  from 
the  list  of  those  to  which  I  apply  this  method.  Any  im- 
portant bowel  complication  above  the  pelvic  brim  must 
be  treated  through  the  abdomen.  Whenever  a  suppu- 
rating ovary  or  tube  communicates  with  a  purulent  ver- 
miform appendix,  and  whenever  a  pus  focus  in  the  adnexa 
opens  into  the  small  intestine,  or  the  large  intestine  above 
the  pelvic  brim,  the  bowel  lesion  so  far  overshadows  the 
pelvic  disease  that  the  case  must  be  viewed  from  the  ab- 


I  58  PELVIC   INFLAMMATION. 

doriiinal  side,  for  the  delicate  suturing  of  the  intestine  can 
not  be  done  through  the  vagina.  The  question  is  natural, 
Can  these  facts  be  determined  by  vaginal  .section?  I  have 
not  found  any  difficulty  in  doing  so  since  the  perfected 
technic  has  been  adopted. 

Whenever  hysterectomy  is  indicated  upon  a  puerperal 
uterus,  the  vessels  are  so  large  that  by  hemisection  too 
much  blood  is  lost,  hence  the  uterus  must  be  removed 
en  masse  ;  and  the  tissues  are  so  friable  that  the  requisite 
down-traction  is  impossible.  Vaginal  ablation  of  a  puer- 
peral uterus  is  truly  a  deplorable  operation  and  one  which 
should  never  be  done. 

But  there  are  a  number  of  cases  which  when  treated 
by  laparotomy  give  a  very  high  rate  of  mortality — I  refer 
to  cases  of  diffuse  suppuration.  When  approached  by 
the  vagina  these  are  as  successfully  handled  as  any 
others. 

Posture. — The  uterus  can  be  removed  per  vaginam 
with  the  patient  in  the  lithotomy  posture  throughout  the 
entire  manoeuvre;  but  the  operator  will  find  that  he  can 
proceed  with  greater  comfort  to  himself  and  safety  to  his 
patient  if  he  employs  a  table  which  enables  him  to  secure 
the  Trendelenburg  posture.  The  one  I  have  devised 
can  be  employed  in  all  gynecological  work  and  is  par- 
ticularly useful  in  the  vaginal  operations;  but  a  suitable 
table  may  be  improvised  by  sawing  off  two  of  the  legs 
of  a  stout  kitchen  table  so  that  the  incline  of  the  table 
will  be  60°.  To  retain  the  patient  in  the  lithotomy  pos- 
ture I  employ  Ott's  or  Clover's  crutch ;  but  a  sheet  pass- 
ing over  her  shoulders  and  tied  to  the  legs  will  answer. 

Having  a  table  which  enables  him  to  secure  the 
Trendelenburg  posture  at  any  moment,  the  operator  can 
avoid  all  those  accidents  which  accompany  improperly 
applied  and  imperfectly  protected  forceps.  If  he  so 
desires,  he  can  operate  in  a  pelvis  which  is  entirely  free 
from  abdominal  viscera  (Figs.  57,  58,  59). 

Operation. — I  operate  standing.  The  field  of  opera- 
tion is  cleansed,  and  the  uterus  is  curetted  and  swabbed 
out,  but   is    not   packed.     All  instruments  used  in  the 


Fig.  57. — Operating  table  folded  for  transportation. 


^^^ 


Fig.  58. — The  table  in  exaggerated  Trendelenburg  position  for  laparotomy. 

169 


I  70 


PELVIC   INFLAMMATION. 


curettage  are   laid   aside,  and   the  operator  again  washes 
his  hands. 

The  Incisions. — I    always   attempt   and    rarely   fail    in 
inflammatory  cases  to  enter  the  posterior  cul-de-sac  as 


Fjr,.  59. — 'Ilie  author's  table  arranged  for  vaginal  operations  in  the  litliotoiny 

posture. 


the  first  step.     This  is  the  true  exploratory  part  of  my 
operation  (see  Exploration,  page  136). 

Having  become  convinced  that  an  ablation  is  neces- 
sary, the  operator  proceeds  to  spread  the  vaginal  incision 
from  side  to  side  (Fig.  52).  The  posterior  incision  hav- 
ing been  completed  a  gauze  pad  is  introduced  into  the 
opening  to  catch  fluids.  The  anterior  incision  is  next 
made.     I   introduce  into  the  uterus  a  pair  of  my  intra- 


VAGINAT,  AP.LATTON. 


lyr 


uterine  traction  forceps,  and  spread  them  until  a  firm  ^rasp 
is  secured  upon  the  organ  (Fig.  6i). 

The  cervicovesical  fold  is  accurately  determined,  and, 


/^ 


c 


Fig.  60. — The  lines  of  incision  in  the  vaginal  operations.  A-B,  the  extent 
of  the  incision  into  the  posterior  cul-de-sac  for  the  purpose  of  severing  adhe- 
sions. X-Y,  the  incision  for  evacuating  pus,  in  puerperal  fever  and  in  hys- 
terectomy.    C-D,  The  anterior  incision  for  dissecting  off  the  bladder. 

cutting  against  the  cervix,  the  latter  is  circled  to  within 
an  eighth  of  an  inch  of  the  posterior  cut.  Thus  a  nar- 
row strip  of  vaginal  mucosa  is  left  upon  each  side,      I  do 


Fig.  61. — The  author's  intra-uterine  traction  forceps. 

not  make  this  anterior  incision  near  the  external  os.  I 
wish  to  cut  above  the  very  dense  tissues  about  the  exter- 
nal OS  and  yet  to  leave  abundance  of  vagina.  If  the  dis- 
section is  made  near  the  os,  bilateral  space  is  secured 


1^2  PELVIC   INFLAMMATION. 

with  difficulty,  for  the  incision  will  be  surrounded  by  a  ring 
of  inelastic  tissue  (Fig.  62).  In  other  words,  the  anterior 
incision  should  be  made  in  vaginal  tissue  and  not  in  cer- 
vical. So  soon  as  the  scissors  have  cut  through  the 
vaginal  mucosa,  they  are  closed  and  laid  sideways  upon 


Fig.  62. — Shows  microscopic  section  (vertical)  of  fetal  bladder,  urethra, 
anterior  vaginal  wall,  and  anterior  lip  of  cervix,  a  lies  above  loose  tissue, 
between  bladder  and  cervix  and  vagina;  3,  bladder;  u,  urethra;  v,  vagina;  c, 
cervix  uteri.  X  marks  the  point  at  which  the  anterior  incision  is  made,  so 
that  the  dissection  may  proceed  through  the  loose  tissue  between  cervix  and 
bladder  (Hart). 

their  edge  in  the  cut.  Bearing  down  hard  upon  the  cer- 
vix, the  tissues  are  shoved  up  for  a  short  distance  or 
until  the  looser  tissues  are  reached.  The  closed  scissors 
used  in  this  way  act  as  does  a  periosteum  elevator. 
After  the  dissection  has  proceeded  upon  the  anterior  face 


VAGINAL  ABLATION. 


173 


of  the  cervix  for  about  half  an  inch,  a  short  retractor  is 
inserted  into  the  wound  and  the  bladder  held  up.  Upon 
wiping  the  wound  dry  a  few  bands  of  connective  tissue 
and  muscular  fiber  may  be  noticed  extending  from  the 
sides  of  the  incision  toward  the  center  and  angle  of  the 
denudation.  These  are  snipped  with  the  scissors.  After 
this  all  attempts  to  enter  the  anterior  peritoneal  pouch 
are  made  with  one  finger.  Holding  the  uterus  firmly 
with  the  intra-uterine  traction,  the  vesico-uterine  tissues 
are  pushed  up.     The  operator  does  this  by  bearing  hard 


.•^  C- 


\3  '    '^^ 


Fig.  63. — Transverse  section  of  right  half  of  uterus  at  level  of  the  internal  os. 
c,  bladder;  a,  uterus;  i,  parametric  tissue;  X,  uterine  vessels  (Hart). 

down  upon  the  uterus  with  the  index  finger  and  literally 
rubbing  the  bladder  tissues  from  the  uterus.  This  is 
done  not  with  the  nail,  but  with  the  palmar  surface  of  the 
finger.  It  is  in  this  bladder  dissection  that  the  great 
value  of  my  forceps  is  seen.  With  them  the  uterus  can 
be  rotated  so  as  to  differentiate  the  loose  pericervical 
tissues  from  the  uterine ;  and  in  stripping  the  bladder 
from  the  uterus  they  furnish  a  most  admirable  point  of 
counter-pressure.  "  They  give  the  operator  a  fixed  body 
to  work  against  and  not  a  movable  one.  I  have  never 
found  it  necessary  to  sever  the  peritoneum  with  instru- 
ments. The  finger,  whenever  it  can  reach  the  fundus 
anteriorly,  will  easily  penetrate ;  and  in  cases  where  the 
peritoneum  is  attached  high  on  the  uterus,  the  periton- 
eum should  not  be  blindly  opened  until  the  uterus  can 


1^4  PELVIC   INFLAMMATION. 

be  pulled  down  after  hemisection.  Having  entered  the 
anterior  fornix  or  made  the  dissection  as  high  as  the  finger 
will  reach,  the  bladder  is  separated  from  the  uterus  to 
the  sides.  The  anatomical  fact  must  here  be  noted  that 
the  width  of  the  bladder  is  greater  than  that  of  the 
uterus,  and  that  the  organ  extends  laterally  upon  the 
broad  ligaments.  The  operator  sticks  to  the  middle 
line  in  separating  the  bladder  and  makes  the  lateral 
separation  by  moving  the  finger,  laid  flat  upon  the 
uterus,  from  side  to  side.  The  uterine  vessels  at  the 
sides  can  be  felt  pulsating,  and  the  dissection  should  not 
be  carried  beyond  their  level  (Fig.  62,).  If  the  operator 
is  rough  he  can  very  easily  rupture  the  uterine  vessels. 
So  far  there  has  been  but  littls  bleeding.  The  azygos 
artery  on  the  posterior  vaginal  wall  has  been  severed  in 
opening  the  cul-de-sac,  and  temporarily  clamped  if  prom- 
inent. The  small  vessels  from  the  uterine  arteries  which 
enter  the  cervix  give  some  trouble  if  wounded.  They 
anastomose  freely  with  the  vesical  arteries.  I  do  not  pay 
attention  to  them  until  I  am  ready  to  clamp  the  uterines. 
The  operation  has  progressed  to  the  point  where  the 
uterus  is  free  from  its  attachments  to  the  bladder  and 
posterior  vaginal  wall.  I  have  termed  this  the  first 
stage ;  for  it  is  done  in  all  cases,  be  the  further  manceu- 
vres  what  they  may.  In  making  these  incisions  and 
separating  the  bladder,  what  is  the  position  of  the  ure- 
ters  ?  At  the  point  where  the  uterine  artery  springs 
from  the  internal  iliac,  the  ureter  lies  at  least  a  quarter 
of  an  inch  below  the  artery.  As  the  artery  abruptly 
crosses  the  pelvis  to  the  side  of  the  uterus  it  passes 
across  the  ureter.  This  point  of  crossing  is  always  at 
least  an  inch  from  the  normal  cervix,  and  is  where  the 
broad  ligament  spreads  out  for  its  attachment  to  the 
side  of  the  pelvis  (Fig.  64).  After  this  the  ureter  and 
uterine  artery  are  never  in  relation.  The  ureter  sweeps  in 
a  graceful  curve  to  the  bladder  and  is  hi  front  of  the  uter- 
ine artery.  The  uterine  artery  does  not  curl  around  the 
ureter,  as  pictured  by  Bourgery  and  Jacob.  From  the 
time  the  ureter  crosses  the  pelvic  brim,  it  begins  to  sink 


Fig.  64. — A.,  abdominal  aorta;  I.  I.,  internal  iliac  artery;  E.  I.,  external 
iliac  artery  ;  O.  A.,  ovarian  artery  ;  U.  A.,  uterine  artery  ;  R.,  rectum  ;  F.,  a 
fibroid  nodule  springing  from  the  fundus;  Ut.,  uterus;  O.,  over  the  right 
ovary  which  is  adherent  to  the  posterior  surface  of  the  broad  ligament. 
Above  O  is  a  right  hydrosalpinx  ;  U.,  ureter  into  which  has  been  introduced 
a  probe  ;  B,  bladder  ;  S.  V.,  superior  vesical  artery.  The  pelvis  is  somewhat 
tilted  to  the  right  to  show  the  relations.  The  peritoneum  has  not  been 
removed,  but  the  course  of  the  vessels  has  been  shown  by  painting  over  their 
course  beneath  the  peritoneum. 


VAGINAL   ABLATION. 


177 


below  the  internal  iliac  artery ;  and  when  the  uterine 
artery  is  reached,  the  ureter  is  easily  a  quarter  inch  below 
the  uterine.  The  ureter  proceeds  anteriorly  to  the  bladder, 
while  the  uterine  artery  crosses  the  pelvis  to  the  cervix. 
Upon  separating  the  bladder  from  the  uterus  and  lifting 
it  up,  the  ureters  are  swung  outward  and  further  up- 
ward;   and    pulling  the   uterus    down    and    toward   the 


Fig.  65. — A  photograph  of  a  suprapubic  hysterectomy,  introduced  for  the 
purpose  of  demonstrating  the  position  of  the  ureter,  which  may  be  seen  cross- 
ing beneath  the  uterine  artery  at  the  outer  margin  of  tlie  spHt  broad  hgament. 

sacrum  while  lifting  the  bladder  still  further  moves  the 
uterine  artery  to  a  deeper  and  more,  posterior  position. 
When  the  bladder  is  separated  and  held  up,  and  the 
uterus  pulled  down,  the  ureters  and  uterine  arteries  are 
further  apart  than  they  were  before  the  operation.  But 
if  the  bladder  is  not  separated  and  lifted,  down-traction 


178 


PELVIC   INFLAMMATION 


upon  the  uterus  decreases  the  angle  of  divergence 
between  the  artery  and  ureter,  and  they  may  be  made  to 
touch  for  the  outer  half  of  the  artery  and  up  to  a  half 
inch    of  the    cervix.     Repeated    dissections    show    this. 


Fiu.  66. — K,  kidney;  U,  ureter;  a,  ovarian  artery;  B,  external  iliac  vein ; 
Ut,  uterus;  i,  abdominal  aorta;  2,  vena  cava  inferior,  on  each  side  of  which 
is  a  common  iliac  artery;  2',  internal  iliac  vein  ;  x,  middle  sacral  artery;  3, 
external  iliac  artery  ;  4,  internal  iliac  artery  ;  5,  internal  pudic  artery  ;  6,  uterine 
artery;  6',  point  where  uterine  artery  joins  the  severed  ovarian  artery;  7, 
vaginal  artery  ;  8,  8',  superior  vesical  artery  ;  9,  obturator  artery  ;  10,  common 
origin  of  the  gluteal  and  sciatic  arteries. 


The  ureters  can  not  be  wounded  by  any  force  applied  at 
the  sides  of  the  uterus,  provided  such  force  does  not 
tend  to  draw  the  cervix  and  bladder  together,  as,  for 
iiistance,  an  improperly  applied  ligature  does. 


-h 


yf^;-'-  • :: 


Fig.  66.* — Surgical  Anatomy  of  the  Internal  Iliac. 


VAGINAL    ABLATION. 


179 


I  leave  a  narrow  strip  of  vaginal  mucous  membrane 
upon  each  side  and  between  my  anterior  and  posterior 
incisions  for  two  reasons.  When  I  apply  the  forceps  to 
the  uterine  vessels,  this  strip  of  tissue  prevents  tearing 
off  the  forceps  during  future  manipulations.  Further- 
more, I  have  thought  this  prevented  to  some  extent  sag- 
ging down  of  the  vagina  after  completion  of  the  process 
of  healing,  inasmuch  as  the  vaginal  vault  and  the  bases 
of  the  broad  ligament  are  one. 

I  have  never  found  that  my  incisions  gave  me  less 
room  than  Segond's.  This  surgeon  circles  the  cervix 
entirely,  and  makes  upon  each  side  a  cut  at  the  base  of 
the  broad  ligament.  I  never  find  it  necessary  to  incise 
the  perineum  to  gain  space.  Could  I  not  perform  the 
operation  without  this,  I  would  always  do  laparotomy. 
One  attractive  feature  about  this  vaginal  operation  is 
absence  of  traumatism  to  normal  structures.  This  is 
lost  when  the  perineum  is  incised. 

When  Segond  has  separated  the  bladder  he  has  two 
flaps,  and  his  first  pair  of  forceps  do  not  grasp  vaginal 
mucous  membrane  at  all.  Segond  contends  that  his 
incision  enables  him  the  better  to  avoid  the  ureters.  In 
one  way  it  does,  inasmuch  as  there  is  a  greater  separation 
of  the  anterior  (bladder  and  ureters)  segment  from  the 
posterior  (uterus),  not  in  the  middle,  but  at  the  sides  of 
the  uterus.  I  have  used  both  incisions  and  prefer  the 
one  illustrated,  for  the  reasons  stated. 

In  certain  cases  the  bladder  is  attached  so  high  up  on 
the  anterior  surface  of  the  uterus  that  the  operator  cannot 
reach  the  anterior  peritoneum  with  his  finger.  He  should 
then  make  his  dissection  as  high  as  he  can,  and  withdraw 
the  intra-uterine  traction  forceps.  In  order  to  enter  the 
peritoneum  it  is  necessary  for  him  to  pull  down  the  ante- 
rior surface  of  the  uterus.  In  order  to  do  this,  he  grasps 
each  side  of  the  cervix  with  bullet  forceps,  and  splits  the 
anterior  lip  of  the  cervix  in  the  middle  line  to  a  little 
above  the  level  of  the  internal  os.  (See  Hemisection.) 
Upon  rotating  the  bullet-forceps  outward  the  cervical 
canal  will  flare  out,  and  a  portion  of  the  anterior  uterine 


I  So  TELVIC   INFLAMMATION. 

wall  will  come  down.  This  is  cut  with  scissors  in  the 
middle  line.  While  making  this  anterior  median  section 
of  the  uterus,  the  bladder  should  be  held  up  by  a  narrow 
retractor,  and  as  each  successive  portion  of  the  anterior 
wall  of  the  uterus  conies  into  view,  it  is  grasped  by  trac- 
tion forceps.  After  a  time,  at  the  upper  angle  of  his  in- 
cision, the  operator  will  see  the  smooth  peritoneal  cover- 
ing of  the  uterus.  He  has,  perhaps  unconsciously,  entered 
the  anterior  peritoneal  pouch  by  holding  up  the  bladder 
and  progressively  sj^litting  the  anterior  face  of  the  uterus. 
It  is  well  after  entering  the  peritoneum  posteriorly 
and  anteriorly  to  make  a  careful  digital  exploration  of  the 
pelvis.  Now  is  the  time  for  the  operator  to  obtain  an 
accurate  knowledge  of  the  regional  anatomy  of  the  par- 
ticular pelvis  he  is  dealing  with.  This  completes  the  first 
stage  of  the  operation,  and  the  procedure  is  employed  in 
all  cases. 

ABLATION  EN  MASSE. 

Freeing'  the  Adnexa. — If  this  can  possibly  be  done 
before  the  application  of  the  forceps,  it  should  be,  for 
forceps  take  up  room.  The  gauze  pad  in  the  cul-de-sac 
is  removed.  Still  pulling  the  uterus  down,  the  operator 
inserts  his  finger  into  the  pouch  of  Douglas.  Taking  the 
posterior  surface  of  the  uterus  as  a  guide,  he  enters  the 
finger  to  the  level  of  the  tubes.  After  one  tube  is  found, 
attempts  are  made  to  free  its  attachments  at  the  fimbriated 
end.  In  doing  this  the  effort  is  made  to  pusJi  up  the  tube 
and  ovary.  The  operator  is  working  from  behind  the 
broad  ligament.  If  the  adnexa  are  attached  low,  they 
can  readily  be  freed.  If  they  are  high  at  the  pelvic  brim, 
the  effort  to  release  them  is  made  in  front  of  the  uterus, 
the  fingers  being  between  the  bladder  and  uterus.  Here 
the  uterus  is  again  the  fixed  guide.  In  working  from  in 
front  of  the  uterus  the  operator  seeks  to  free  the  adhe- 
rent organs  by  getting  his  finger  outside  of  them  and' 
separating  the  attachments  toward  the  cornu.  The  action 
is  very  similarto  that  used  in  like  cases  when  laparotomy 
is  done.     Having  released  the  adnexa  on  one  side,  those 


VAGINAL   ABLATION.  i8i 

of  the  other  are  released.  Too  much  emphasis  can  not 
be  laid  upon  the  importance  of  persisting  in  efforts  to 
release  the  adnexa  from  inflammatory  union  to  other  or- 
gans before  putting  on  any  forceps.  No  vessels  of  im- 
portance have  so  far  been  severed ;  the  narcosis  is  not 
profound,  and  the  patient  is  in  no  sort  of  danger.  The 
operator  need  not  be  embarrassed  if  he  finds  the  adnexa 
firmly  adherent,  but  must  persist  in  his  efforts  to  free  them 
both  by  working  from  behind  and  from  in  front  of  the 
uterus.  It  is  well  to  have  a  firm  grasp  upon  the  cervix 
with  blunt  traction  forceps  or  the  intra-uterine  traction 
forceps,  and  to  work  with  all  specula  removed.  As  few 
instruments  as  possible  should  be  in  the  vagina.  While 
drawing  down  the  uterus  with  the  left  hand  and  manipu- 
lating the  adnexa,  the  assistant  will  render  material 
aid  by  pressing  down  from  above  the  pubes.  When 
he  has  released  the  adnexa,  the  operator  withdraws 
his  hand  and  introduces  the  anterior  and  posterior 
retractors  (Fig.  67). 

Taking  in  his  right  hand  a  pair  of  hysterectomy  for- 
ceps, the  operator  introduces  one  blade  into  the  anterior 
incision,  to  the  left  of  the  cervix,  and  the  other  blade  into 
the  posterior  incision.  The  forceps  is  crowded,  still 
open,  hard  up  alongside  the  cervix,  and  when  in  position 
the  operator  carefully  inspects  and  feels  each  blade  to  see 
that  no  intestine  or  omentum  is  caught.  The  forceps  is 
then  locked.  A  forceps  is  similarly  applied  upon  the  right 
side.  It  will  now  be  seen  that  all  bleeding  about  the  cer- 
vix has  ceased.  Into  the  posterior  cul-de-sac  a  gauze  pad 
is  inserted  to  hold  up  the  intestines;  and  the  tissues  upon 
each  side  of  the  cervix  between  the  cervix  and  the  two  for- 
ceps are  cut  with  scissors  almost  to  the  points  of  the  for- 
ceps. The  intra-uterine  traction  forceps  or  a  male  sound 
is  now  used  to  antevert  the  uterus.  As  high  on  the  ante- 
rior face  of  the  uterus  as  he  can  see,  the  operator  takes  a 
firm  grasp  of  the  uterus  with  toothed  forceps  and  with- 
draws the  intra-uterine  traction  (Fig.  68).  He  shoves 
the  cervix  upward  while  he  pulls  down  on  the  body  of 
the  uterus  until  he  can  see  more  of  it,  and  again  takes  a 


I.S2 


I'la.VIC;    INFLAMMATION. 


good  grasp  near  tlic  fundus.  He  can  now  draw  the  fun- 
dus forward  beneath  the  bladder  until  the  cornua  appear. 
While  supporting  the  fundus  in  this  way  he  inserts  his 
fingers  above  the  uterus,  and  seizes  the  right  adnexa. 


Fig.  67. — The  cul-de-sac  has  l)eeii  opened  and  llie  bladder  dissected  from 
the  uterus.  The  uterine  arteries  are  grasped  by  forceps  and  the  eervi.x  has 
been  dissected  from  the  lateral  stumps  (photograph -of  operation). 

Either  with  his  fingers  alone,  or  assisted  by  Luer's  for- 
ceps (Fig.  69),  he  drags  the  right  adnexa  in  front  of  the 
uterus  and  applies  forceps  to  the  right  ovarian  artery 
outside  the  right  ovary.  This  forceps  is  applied  from 
above,  and  the  operator  can  guide  the  anterior  blade  with 


VACINAL    Mil.ATION. 


183 


his  index  finger,  and  the  posterior  blade  with  his  middle 
finger,  so  that  there  is  no  danger  of  catching  any  intestine. 
It  is  well  to  withdraw  the  gauze  pad  before  applying  this 
forceps  lest  it  be  caught  in  the  forceps.  When  he  feels 
that  this  forceps  laps  the  one  on  the  right  uterine  artery, 


Fig.  68. — 'I'he  cervix  has  been  shoved  up  so  as  to  permit  the  operator  to 
drag  the  fundus  out  beneath  the  bladder.  Both  cornua  uteri  are  shown  with 
the  attached  tubes  (photograph  of  operation). 

he  clamps  it.  In  isolating  the  right  adnexa  and  applying 
this  forceps,  if  retractors  are  used  and  are  in  the  way, 
they  should  be  withdrawn.  The  upper  forceps  grasps 
the  round  ligament  as  well  as  the  broad  ligament.  The 
uterus  is  now  cut  loose  upon  the  right.  At  once  it 
swings  out  of  the  pelvis  so  that  its  posterior  face  is  for- 


184 


PELVIC   INFLAMMATION. 


ward,  and  it  becomes  an  easy  matter  to  bring  forward  the 
left  adnexa  and  secure  the  left  ovarian  artery  outside  the 
ovary.     The  uterus  can  now  be  cut  away  (Fig.  70). 

The  specula  are  next  introduced.    Holding  the  bladder 


l''l(i.  69. — Aiier  delivering  lue  fundus  the  eni.ic  uienne  bod\  is  |Hilled  to 
the  operator's  right,  in  order  that  the  riglit  adnexa  may  be  seized.  Tlie  oper- 
ator's thiunl5  rests  on  the  ovar}',  wliile  his  two  first  fingers  grasjj  the  corpus 
uteri.  The  forceps  are  being  apphed  to  tlie  right  ovarian  artery.  Notice  the 
aljsence  of  retractors  (photograph  of  operation). 

up  and  depressing  the,  perineum  and  posterior  wall,  the 
operator  introduces  a  gauze  pad  into  the  pelvis  and  pushes 
the  intestines  away  from  the  stumps  secured  by  his  for- 
ceps, so  that  he   may  make  a  careful   inspection  of  the 


VAGINAT,   ABLATION. 


t8: 


Stumps  and  see  if  any  bleeding  is  going  on.  If  the  ad- 
nexa  have  been  thoroughly  freed  before  extirpation  is 
attempted,  it  will  be  seen  upon  completion  of  the  opera- 


FlG.  70. — Having  clasped  the  right  ovarian  artery,  the  uterus  is  cut  away 
upon  that  side.  The  operator  rotates  the  uterus,  so  that  the  cervix  is  deliv- 
ered and  the  posterior  surface  of  the  uterus  presents.  He  grasps  the  left  broad 
ligament  between  his  index  and  middle  fingers,  and  applies  the  forceps  to  the 
left  ovarian  artery.  The  method  of  applying  these  forceps  is  shown  (photo- 
graph of  operation). 

tion  that  the  bite  of  each  pair  of  forceps  is  in  the  upper 
part  of  the  vagina.  No  forceps,  if  possible,  should  ever 
be  applied  so  as  to  project  up  into  the  pelvic  cavity  among 
the  intestines.     The  gauze  pad  supporting  the  intestines 


T  M6 


I'ELVIC   INFLAMMATION. 


is  now  removed,  and  a  piece  of  iodoform 
gauze  is  inserted  between  the  forceps  and 
the  wall  of  the  vagina  on  each  side  to  pre- 
vent pressure-slough.     The  operator  now 
takes    squares   of  iodoform    gauze,  each 
about  two  inches  wide  and  three   inches 
long,  and  introduces  one  piece  along  the 
side  of  the  forceps  on  the  left,  a  little  above 
their  tips.     This  piece  of  gauze   is  sup- 
ported by  a  smooth,  narrow  speculum  in- 
troduced to  the  right  of  it;  the  dressing 
forceps  is  removed,  another  piece  of  gauze 
:     introduced   alongside  the  speculum,  the 
I    speculum    withdrawn,    and   this  piece  of 
]     gauze  also  supported.     In  this  way  the 
L"    operator  proceeds  from  one  side   to  the 
:     other,  filling  the  opening    in  the  vagina 
i    entirely  with  iodoform  gauze,  which  pro- 
3    jects  a  little  above  the  points  of  the  for- 
3     ceps.     A  ^e\\f  more  pieces  of  gauze  are  in- 
:     troduced  lower  down  in  the  vagina,  so  as 
?     to  fill  it  to  the  vulvar  orifice.     Sterilized 
\     gauze  is  wrapped  around  all  the   forceps 
T    and  tied.     A  self-retaining  catheter  is  in- 
\    troduced  into   the  bladder  upon  a  sound 
and  pinned  to  a  piece  of  plaster  fastened 
to  the    skin  above   the    pubes  (Fig.  71). 
The  sphincter  ani  is  dilated,  and  the  pa- 
tient put  to  bed. 

Sometimes,  when  the  adnexa  of  one  side 
are  so  firmly  attached  to  the  intestines,  or 
are  so  large,  or  the  vulva  is  so  small  that 
the  operator  cannot  loosen  both  adnexa  to 
his  satisfaction,  he  may  proceed  as  follows : 
If  the  difficulty  be  limited  to  one  side  only 
— for  example,  the  right  side — he  may  free 
the  adnexa  on  the  left  side,  secure  the 
uterine  arteries  on  both  sides,  and  the 
ovarian  artery  on  the  left  side  outside  the  ovary  and  tube; 


.    IVAGINAL   AI5T,ATI()N.  187 

he  then  cuts  the  uterus  free  on  the  left  side.  Having 
done  this,  he  introduces  a  pair  of  forceps  close  to  the 
uterus  upon  the  right  side  where  the  adnexa  have  not  been 
freed,  and  removes  the  uterus  and  adnexa  of  the  left  side, 
leaving  in  the  tissues  which  embarrassed  him.  It  will 
now  be  found  that  he  will  have  room  for  removing  the 
remaining  adnexa  under  the  guidance  of  the  eye.  To 
do  this  the  operator  will  secure  the  ovarian  artery  outside 
the  ovary  and  tube.  This  will  render  the  forceps  which 
was  applied  between  the  uterus  and  right  adnexa  unne- 
cessary, so  it  may  be  removed.  This  is  in  reality  but 
a  form  of  morcellation  or  removal  in  fragments. 

While  the  removal  of  the  uterus  en  masse  is  more  gen- 
erally accepted  than  any  other  method,  I  am  pursuaded 
that  it  is  responsible  for  many  of  those  ill  results 
which  lend  arguments  to  the  opponents  of  the  vaginal 
method.  In  certain  cases  it  is  utterly  impossible  to 
remove  the  uterus  and  adnexa  entire.  Such  cases  are 
those  where  the  uterus  is  much  enlarged,  where  the  pus 
foci  are  enormous  or  attached  high  at  the  pelvic  brim, 
and  cases  of  advanced  genital  sclerosis.  It  may  be 
found  impossible  to  free  the  adnexa  before  applying 
forceps,  and  equally  so  after  forceps  have  fixed  the 
tissues. 

Appreciating  the  difficulty  of  ablation  en  masse,  I  have 
for  several  years  practised  exclusively  ablation  by  hemi- 
section.  This  I  sometimes  supplement  by  morcellation, 
but  the  morcellation  is  employed  merely  as  a  step  pre- 
liminary to  the  hemisection. 

ABLATION   BY    HEMISECTION. 

"  I  divide  my  difficulties  by  splitting  the  uterus." 
This  is  the  operation  which  I  always  employ.  It  is  the 
operation  of  election  in  all  cases,  whether  associated  with 
fibroid  degeneration  or  not.  In  such  cases  it  is  some- 
times associated  with,  but  never  supplanted  by  morcella- 
tion. By  means  of  this  procedure,  the  time  consumed 
in  operating  is  rarely  twenty  minutes,  and  the  operation 


1 88  PELVIC   INFLAMMATION. 

is  "always  complete.  Rcineiiibering  his  anatomy,  the 
operator  recalls  that  both  upon  its  anterior  and  posterior 
surfaces,  the  uterus  is  comparatively  sparsely  supplied 
with  vessels,  along  the  middle  line.  Therefore,  an  abso- 
lutely median  section  produces  but  little  hemorrhage. 
The  time  of  operating  is  short,  for,  by  means  of  the 
hemisection,  each  set  of  adnexa  and  its  corresponding 
half  of  the  uterus  are  rendered  movable.  Further,  as 
one-half  of  the  severed  uterus  is  shoved  up  into  the 
pelvis,  out  of  the  way,  the  hand  is  enabled  to  work  high 
in  the  pelvis  to  the  side  of  that  half  of  the  uterus  which 
is  drawn  down,  and  the  fingers  have  all  the  space  to  one 
side  in  which  to  work,  from  the  bladder  to  the  perineum. 
One  other  advantage  is  that,  as  each  half  of  the  uterus  is 
liberated  and  drawn  down,  it  is  swung  outside  the  vagi- 
nal outlet,  giving  an  unobstructed  orifice  in  which  to 
work. 

Operation. — First  Stage. — The  patient  is  on  the  back 
and  in  the  lithotomy  position.  A  short  Jackson  specu- 
lum draws  down  the  perineum.  The  uterus  is  curetted 
and  swabbed  out,  but  not  packed.  The  intra-uterine 
traction-forceps  is  introduced,  and  the  posterior  cul-de- 
sac  is  opened  (Fig.  72).  All  adhesions  posterior  to  the 
uterus  along  the  middle  line  are  severed  by  the  examin- 
ing finger  up  to  the  fundus.  No  attempt  is  made  to  fur- 
ther separate  the  adherent  organs  at  this  stage.  It  can 
not  be  now  properly  done  and  is  a  waste  of  time.  The 
posterior  incision  is  carried  around  the  cervix,  almost  to 
the  middle  line.  Drawing  down  the  uterus  and  holding 
up  the  bladder,  the  anterior  cervico-vaginal  juncture  is 
severed  by  means  of  the  scissors.  This  cut  is  not  to  be 
made  close  to  the  external  os,  but  is  above  the  dense 
cervical  structure,  and  in  the  loose  pericervical  tissue. 
The  fold  at  which  the  incision  is  made  is  easily  seen 
when  the  uterus  is  shoved  up.  This  incision  is  carried 
laterally  toward  the  posterior  cut,  but  stops  one-eighth 
inch  from  it  on  each  side.  As  this  incision  is  made,  a 
few  fine  arterioles  spurt.  They  are  not  important,  being 
but   small    anastomotic   branches    between    the    uterine 


Fig.  72. — Showing  the  method  of  incising  the  vagina  at  the  point  x  in  Fig. 
62.  The  intra-uterine  traction  forceps  is  shown  pulling  the  uterus  down. 
The  second  step  in  all  vaginal  ablations  (from  a  photograph  of  an  operation 
by  the  author). 


Fig.  73. — The  cervix  is  split  anteriorly.     The  first  step  in  hemisectioii  (from 
a  photograph  of  an  operation  by  the  autlior). 


F.IG.  74- — Showing  the  effect  of  sphtthig  the  anterior  uterine  wall  so  that 
the  uterus  may  be  rolled  from  beneath  the  bladder  (from  a  photograph  of  an 
operation  by  tlie  author). 


VAGINAL  ABLATION. 


193 


and  vesical  arteries.  The  assistant  digs  the  shorty  narrow 
Jackson  retractor  into  the  anterior  cut,  with  the  edge 
planted  hard  against  the  cervix.  This  is  the  way  to 
avoid  wounding  the  bladder.  The  uterus  is  then  rotated 
by  twisting  the  intra-uterine  traction  forceps,  and  the 
operator  is  thus  enabled  accurately  to  determine  the 
loose  tissue  between  the  bladder  and  uterus  which  he  is 
to  cut.  As  these  fibers  are  severed  with  scissors  the 
retractor  draws  the  bladder  further  and  further  upward, 
while  the  uterus  sinks  lower  as  it  becomes  free.  Another 
simple  way  of  severing  the  connection  between  the  uterus 
and  bladder  is  by  blunt  dissection  with  the  finger.  In 
doing  this,  the  traction  forceps  is  invaluable,  as  it  fur- 
nishes a  hard  surface  upon  which  to  press.  This  dis- 
section is  made  by  shoving  up  the  pericervical  tissues 
with  the  finger  pressed  hard  against  the  cervix.  The 
point  of  the  finger  is  never  allowed,  to  wander  away  from 
the  uterus.  If  this  rule  is  adhered  to,  the  bladder 
will  not  be  wounded.  The  dorsum  of  the  finger  is 
upward,  and  the  actual  dissection  is  effected  by  a  sort  of 
rubbing  motion  with  the  palmar  face  of  the  end  of  the 
finger  :  the  bladder  is  rubbed  off  the  uterus.  If  the 
incision  is  made  close  to  the  external  os,  this  dissection 
is  most  difficult ;  but  if  made  as  I  suggest,  it  is  easy. 
After  the  uterus  is  free  in  front  and  behind,  the  first  stage 
is  finished. 

Second  Stage. — Two  pairs  of  bullet  forceps  are  made 
to  grasp  the  angles  of  the  external  os,  and  the  intra- 
uterine traction  forceps  are  withdrawn.  The  two  index 
fingers  are  introduced  between  the  bladder  and  the 
uterus,  and  the  bladder  is  further  separated  from  the 
uterus  to  the  sides  of  the  latter.  This  will  remove  the 
ureters  from  all  possibility  of  injury.  The  bladder  is 
held  up  out  of  the  way,  while  assistants  draw  down  on 
the  bullet  forceps.  The  blunt  scissors  are  inserted  as  a 
sound  to  determine  the  direction  and  shape  of  the  uter- 
ine cavity,  and  are  then  withdrawn.  As  far  up  on  the 
anterior  surface  as  the  operator  can  see,  he  splits  the 
uterus   in  the   middle  line.     The  assistants  evert  these 


194 


PELVIC   INFLAMMATION. 


edges  by  twistin<^  the  bullet  forceps  outward,  and  the 
upper  end  of  each  side  is  grasped  with  P'rencli  traction 
forceps  (Fig.  73).  As  these  are  drawn  upon  and  rotated 
outward,  it  will  be  found  that  more  of  the  uterine  body 
comes  into  view,  and  is  unfolded  so  that  the  uterine  cav- 
ity is  flattened  out.  All  of  the  uterine  cavity  that  can  be 
seen  is  split  in  the  middle  line,  and  other  traction  forceps 
are  entered  higher  up.  In  this  way  the  fundus  is  reached 
and   severed  (Fig.  74).     All   specula  are  now  withdrawn, 


Fli;.  75.  — Tiie  author's  retracting  grooved  director.     Of 
soft,  friable  uteri. 


n-eat  service  with 


and  my  grooved  director  (Fig.  75)  is  introduced  behind 
the  uterus,  entering  behind  the  cervix.  A  finger  is  in- 
serted behind  the  bladder  and  the  director  is  felt;  and 
again  the  finger  is  forced  behind  the  uterus  to  see  that  no 
guts  lie  between  the  director  and  the  uterus.  The  assistant 
is  told  to  press  down  the  perineum  hard  with  the  director, 


Fir,.  76. — Ijistourv  for  sphltiiig  tlie  uteru.s 


while  the  curved  portion  of  the  instrument  pulls  forward 
the  uterus.  A  short  speculum  is  inserted  behind  the  blad- 
der until  the  groove  in  the  director  is  seen.  Into  this  a 
special  bistoury  is  inserted  (Fig.  yG),  and  the  uterus  is 
split  accurately  in  two  halves.  This  completes  the  sec- 
ond stage  (Fig.  jf). 

Third  Stage. — The  director  is  drawn  out.  The  right 
(on  operator's  left)  adnexa  and  half  of  uterus  are  shoved 
into  the  pelvis,  while  traction  is  made  upon  the  left  half 


•,\\ 


Fig.  77. — The  anterior  wall  of  the  uterus  has  been  split  until  the  organ  has 
been  rolled  from  beneath  the  bladder.  The  author's  grooved  director  is 
shown  circling  the  uterus  and  the  bistoniy  is  in  place  preparatory  to  the  final 
step  in  heniisection. 


VAGINAL    AliLATION. 


197 


of  the  uterus.  Did  I  not  leave  a  narrow  strip  of  vaginal 
mucosa  upon  each  side  when  I  shove  up  this  half  of  the 
uterus,  the  uterine  artery  would  be  torn  from  its  bed  and 
its  branches  to  the  cervix  broken.     After  this  has  been 


Fig.  78. — The  uterus  having  been  split  into  halves,  one  half  is  rolled  out 
beneath  the  bladder,  and  the  hand  is  thus  allowed  to  enter  the  pelvis.  All 
adherent  organs  can  be  liberated  even  though  attached  to  the  pelvic  brim. 
Note  the  absence  of  retractors  and  artery  forceps  (from  a  photograph  of  an 
operation  by  the  author). 


turned  out  from  beneath  the  bladder,  it  is  swung  to  the 
patient's  left,  and  all  of  the  left  hand  except  the  thumb  is 
inserted  into  the  pelvis  (Fig.  78).  The  left  adnexa  are 
readily  liberated  from  all  adhesions  behind  the  broad  lig- 
ament, as  the  operator  can  reach  the  pelvic  brim.     If  the 


198 


PELVIC   INFLAMMATION. 


vagina  is  relatively  small,  the  operator  allows  the  left 
half  of  the  uterus  and  the  free  adnexa  to  escape  into  the 
pelvis,  and  draws  down  the  right  half  of  the  uterus,  and 
liberates  the  right  adnexa  (Fig.  80).  But  if  there  is  ample 
room,  after  freeing  the  left  adnexa,  they  arc  drawn  in  front 
of  the  cornu  and  a  forceps  is  applied  from  above  downward 
outside  the  ovary  (Fig.  81).   This  is  the  first  attempt  at  hemo- 

stasis.  The  broad  ligament 
is  cut  to  near  the  ends  of 
the  forceps,  and  then  the 
uterine  artery  on  that  side 
is  clamped  from  above 
downward  or  from  below 
upward  close  to  the  cervix, 
as  may  be  most  conve- 
nient. The  points  of  the 
two  forceps  lap,  the  one  on 
the  uterine  artery  being 
exterior  to  that  on  the  ova- 
rian artery  when  put  on 
from  below,  but  internal  to 
the  ovarian  forceps  when 
applied  from  above  (Fig. 
79).  .  In  this  way  splitting 
of  the  broad  ligament  is 
avoided,  and  when  the  up- 

FlG.  79. — 1  lie  forceps   on  tlie   uterine  r                    ■       _,               A      t- 

artery  has  been  placed  from  below,  while  P^f  lOrCCpS    IS    droppeo    It 

that    on    the    ovarian    artery   has    been  will  He  alongside  the  loWCr. 

placed    from  above.       It  will  be  noticed  t„      J      „     '  1^   4-W „     f^..^^^r^ 

'that  the  points  lap.  I"    dropping  this    forccps 

(Fig.  82)  the  upper  portion 
of  the  broad  ligament  is  folded  over  the  forceps  on  the 
uterine  artery,  and  this  forceps  is  kept  from  touching  the 
bladder.  Further,  the  weight  of  the  upper  forceps  posi- 
tively keeps  the  ovarian  artery  stump  on  a  level  with 
the  uterine,  and  at  the  vaginal  vault. 

The  methods  pictured  in  Figs.  83  and  84  are  both 
faulty;  the  latter  for  the  reason  that  the  forceps  will  tear 
the  ligament  when  dropped,  and  the  former  because  some 
risk  is  run   in  putting  the  upper  forceps  on  from  below 


-rM' 


X( 


%. 


i        I 


■M'^ 


Fig.  8o.-  The  right  adnexa  are  shown  drawn  out  ot  the  pelvis  i^reliminary  to 
applj'ing  the  first  pair  of  forceps  to  the  right  ovarian  artery. 


VXl' 


Fl<;.  8i. — The  right  adnexa  are  drawn  across  the  face  ot  the  right  half  of  the 
uterus  and  forceps  is  being  applied  to  the  right  ovarian  artery. 


VAGINAL   ABLATION. 


Upward,  because  (a)  the  points  of  the  forceps  project  too 
high  in  the  pelvis  among  the  intestines,  and  (/;)  the  ova- 
rian artery  is  insecurely  grasped.  The  left  half  of  the 
uterus  is  cut  loose,  and  removed  together  with  the  left 
adnexa.  The  adnexa  and  that  half  of  the  uterus  upon 
the  right  side  are  similarly  treated. 

The  relation  of  the  ureter  to  the  cervix  is  greatly  modi- 


Fin.  82. — After  the  forceps  are  applied  and  dropped  down,  the  upper  forceps 
on  the  ovarian  artery  drags  down  the  broad  ligament  so  that  it  is  folded  over 
the  lower  forceps  on  the  uterine  artery. 

fied  by  the  hemisection.  In  applying  the  forceps  to  the 
uterine  artery  the  cervix  is  sharply  drawn  to  the  opposite 
side.  This  straightens  the  curved  portion  of  the  uterine 
artery,  and  markedly  increases  the  distance  between  the 
cervix  and  the  point  at  which  the  uterine  artery  is  in  re- 
lation with  the  ureter.  It  m^U  be  noticed  that  no  retrac- 
tors are  employed  during  this  stage.  They  are  only  in 
the  operator's  way.  Gauze  pads,  each  secured  by  a  stout 
string,  are  introduced  into  the  pelvis  above  the  forceps. 
The  perineum  is  drawn  down  by  a  long  Jackson  retrac- 
tor, while  the  bladder  is  held  up  by  a  trowel.  The  table 
is  lowered,  and  a  careful  inspection  is  made  of  the  stumps 


PELVIC   INFLAMMATION. 


and  pelvic  contents.  If  bleeding  points  arc  seen,  they 
are  grasped  ;  but  if  the  operator  has  done  his  work  proj)- 
erly,  four  pairs  of  forceps  are  all  that  will  be  needed. 
The  gauze  pads  are  removed,  and  the  pelvis  is  carefully 


Fig.  83.  -  Application  of  clamps 
from  below.  Faulty  method,  as  the 
ovarian  forceps  projects  too  high. 


Fir..  04.  —  Application  of 
clamps  from  above  and  from 
below.  Faulty  method,  .is  the 
forceps  will  not  lie  loosely  when 
dropped,  and  will  tear  the  liga- 
ment. 


cleansed  by  gauze  swabs,  particular  attention  being  paid 
to  the  cul-de-sac.     This  completes  the  third  stage. 

FoJirth  Stage. — Dressings. — "  The  pelvic  Mikulicz."  A 
piece  of  iodoform  gauze  is  inserted  between  the  forceps 
and  the  vagina  upon  each  side.  Each  set  of  forceps  is 
then  drawn  toward  the  lateral  pelvic  wall-  by  means  of  a 


Fig.  85. — The  application  of  the  pelvic  Mikuhcz  dressing.  The  method 
of  liolding  the  dressing  to  one  side  while  successive  pieces  of  gauze  are  intro- 
duced is  to  be  noted. 


VAGINAL   ABLATION. 


205 


long,  narrow  retractor.  Between  them  enough  strip.s  of 
gauze  are  inserted  to  fill  the  space.  These  strips  project 
up  above  the  points  of  the  forceps  (Fig.  85).  The  patient 
is  lowered  to  the  horizontal  position,  and  a  self-retaining 


/ 


Fig. 


-The  completed  operation.     The  forceps  are  shown  surrounded  by 
the  dressings. 


catheter  is  introduced  on  a  sound.  The  sphincter  ani  is 
dilated  thoroughly.  This  is  done  to  allow  of  the  easy 
escape  of  intestinal  gases,  and  to  allay  spasm  of  the  leva- 
tor ani  muscle.  The  opposing  muscle  to  the  levator  ani 
is  the  sphincter.     Under  the  bruising  and  stretching  to 


2o6  PELVIC   INFLAMMATION. 

which  the  levator  is  subjected,  it  is  apt  to  spasmodically 
contract  if  held  down  hard  by  the  undilated  sphincter. 
Patients  who  have  the  sphincter  dilated  are  more  com- 
fortable than  are  those  in  whom  this  is  not  done.  A 
piece  of  plain  gauze  is  wrapped  around  the  forceps  and 
tied.     The  operation  is  completed  (Fig.  86). 

The  method  of  making  these  dressings  is  radically  dif- 
ferent from  that  employed  elsewhere,  I  consider  it  an 
essential  feature  of  my  method.  The  Mikulicz  dressing 
is  employed  here  to  absorb  all  discharges.  It  should  be 
of  sufficient  volume  to  do  this  during  the  week  in  which 
plastic  union  is  taking  place  between  the  rectum  and 
bladder.  But  there  is  another  reason  why  I  pack  these 
cases  so  snugly.  It  is  to  avoid  an  accident  which  not 
infrequently  happens  to  those  who  use  the  gauze  in  slen- 
der strips  only.  When  the  latter  dressing  is  used,  at  the 
time  the  forceps  are  removed,  the  sloughing  ovarian 
stumps  very  often  snap  back  into  the  pelvis,  causing  sec- 
ondary infection.  The  pelvic  Mikulicz  dressing  holds 
these  stumps  immovably  fixed  at  the  vaginal  vault,  and 
I  have  never  seen  such  secondary  infection. 

In  a  case  of  what  I  supposed  was  a  secondary  hemor- 
rhage from  an  ovarian  vessel,  when  I  removed  the  forceps 
on  the  second  day,  I  made  a  rapid  section  of  the  belly. 
There  was  even  at  this  early  day  found  firm  plastic  union 
between  the  bladder  and  rectum,  and  the  field  of  my  va- 
ginal operation  was  found  completely  shut  out  from  com- 
munication with  the  general  pelvic  cavity  The  after 
treatment  usual  after  vaginal  hysterectomy  is  employed. 


>%.•.. 


1 


4 


/     \ 


P 


^^^^^-l«„Mi^  ■ 


Fig.  87. —  Dissection  of  a  body  upon  whom  years  before  a  vaginal  hyster- 
ectomy had  been  performed.  L,  a  calcified  silk  hgature  upon  the  right  uter- 
ine artery  ;  U,  the  left  uterine  artery.  No  trace  of  ligature  was  found  on  this 
vessel  and  the  artery  still  contained  a  small  channel  throughout  its  entire 
length;  B,  bladder;  R,  rectum.  The  manner  in  which  the  vault  of  the 
vagina  becomes  closed  by  a  thin  transverse  line  of  union  is  well  shown. 
Notice  how  the  bases  of  the  broad  ligaments  hold  up  the  vagina.  There  is  no 
tendency  to  hernia,  and  the  posterior  cul-de-sac  is  just  as  deep  as  ever  it  was. 
This  specimen  is  of  value  to  us  as  showing  the  manner  in  which  the  vaginal 
vault  continues  to  be  supported  even  after  removal  of  the  uterus. 


MORCELLATION. 


209 


MORCELLATION. 

The  uterus  is  removed  in  fragments  by  a  process  of 
decentralization. 

There  are  certain  cases  of  very  large  ovarian  abscess 
which  pin  the  uterus  up  against  the  symphysis  and  im- 
movably fix  it  there.  In  such  cases  the  anterior  perito- 
neal space  cannot  be  reached  until  the  uterus  is  either 
split  or  partially  cut  away  as  the  abscess  is  evacuated. 
AH  broad  ligament  accumulations  demand  either  hemi- 
section  or  morcellation.  Such  are  broad  ligament  abscess, 
broad  hgament  hematoma  produced  by  ruptured  ectopic 
gestation,  broad  ligament  cyst  of  large  size,  and  fibroids 
with  intraligamentous  nodules.  Morcellation  is  here  ne- 
cessary because  the  uterus  is  displaced  so  far  upwards  or 
to  one  side  and  the  pelvis  so  blocked  that  to  even  feel 
the  ovarian  region  the  uterus  must  be  removed.  In  such 
cases  the  morcellation  is  atypical.  The  peculiar  relation 
of  these  broad  ligament  growths  to  the  posterior  cul-de- 
sac  must  be  remembered  (see  Exploratioti). 

The  necessity  for  morcellation  is  not  usually  deter- 
mined until  the  attempt  at  removal  by  hemisection  has 
been  found  impracticable.  Indeed,  by  whatever  method 
the  ablation  is  attempted,  a  resort  can  always  be  had  to 
morcellation.  A  most  accurate  knowledge  of  the  minute 
and  regional  anatomy  of  the  parts  is  needed  for  this  op- 
eration. Remembering  that  the  blood  supply  of  the 
uterus  approaches  the  cervical  and  cornual  points  and  has 
lateral  anastomoses  between  the  upper  and  lower  vessels, 
and  that  the  arteries  which  course  across  the  anterior  and 
posterior  surfaces  of  the  uterus  are  small,  the  operator 
feels  secure  in  severing  all  tissue  which  lies  between  the 
lateral  ovarian-uterine  anastomoses.  The  object  in  doing 
this  is  to  so  weaken  the  tissue  in  view  that  more  can  be 
pulled  down  from  above  by  the  process  of  decentraliza- 
14 


2IO  PELVIC   INFLAMMATION. 

tion,  or  removing  the  center,  and  allow  of  diminution  of 
the  bilateral  diameter  of  the  organ.  There  are  two  chief 
ways  of  doing  this.  The  one  most  successful  in  dealing 
with  large  uteri  associated  with  pus  (the  condition  we  are 
discussing)  is  to  weaken  the  anterior  uterine  wall  by  re- 
moving successive  vertical  strips  of  tissue.  Mere  fixation 
of  the  uterus  is  no  indication  for  morcellation ;  the  fixa- 
tion must  be  accompanied  by  marked  enlargement.  Typi- 
cal or  symmetrical  morcellation  is  rarely  possible  when 
dealing  with  pus  cases,  the  operator  often  combining  sev- 
eral methods  in  excavating  the  uterine  wall. 

Operation. — It  is  a  great  aid  if  the  posterior  cul-de-sac 
can  be  opened.  This  is  first  done;  next  the  bladder  is 
dissected  from  the  uterus  until  the  anterior  peritoneal 
pouch  is  opened  up  as  far  as  is  possible.  While  the  blad- 
der is  held  up  by  a  Jackson  speculum  and  the  intestines 
protected  by  a  gauze  pad,  the  anterior  wall  of  the  uterus 
is  split  as  high  as  possible.  Holding  the  everted  edges 
of  the  cut  with  bullet  forceps,  the  operator  trims  a  strip 
of  tissue  about  a  quarter  of  an  inch  wide,  first  from  one 
side,  and  then  from  the  other  (Fig.  88,  i  and  2).  A  half- 
inch  has  now  been  taken  out  of  the  entire  visible  anterior 
uterine  wall.  The  removal  of  this  amount  of  tissue  from 
the  cervix  will  usually  be  all  that  can  be  taken  away  with- 
out reaching  its  sides.  The  other  slices  cut  out  will  be 
above  the  cervix  and  limited  to  the  body  of  the  uterus.  In 
most  cases  it  will  be  found  that  the  removal  of  the  first  two 
strips  has  so  weakened  the  anterior  uterine  wall  that  the 
median  splitting  of  the  anterior  wall  can  be  continued, 
and  the  cornua  uteri  can  be  brought  into  view  beneath 
the  bladder  (3  and  4  of  Fig.  88).  But  in  some  cases  the 
bladder  is  attached  so  high  up  upon  the  uterus  that  the 
dissecting  finger  can  not  effect  the  separation.  Then  it 
will  be  necessary  to  split  the  uterus  up  as  high  as  possi- 
ble and  remove  from  each  side  one,  and  perhaps  two 
wedge-shaped  pieces  with  their  bases  upward  (5  and  6  of 
Fig.  88).  The  stumps  are  firmly  grasped  and  the  ante- 
rior wall  pulled  further  down,  while  the  bladder  is  pushed 
up  so  as  to  expose  more  of  the  uterine  tissue.     What 


MORCELLATION. 


appears  is  again  split  in  the  middle  line,  and  from  each 
side  a  wedge  of  tissue  is  removed  (7  and  8  of  Fig.  88). 
Progressively  pulling  down  the  uterus  and  cutting  out 
pieces,  the  cornua  appear.  So  far  there  has  been  free  cap- 
illary bleeding,  but  none  from  vessels  of  large  size.  There 
has  been  no  hemostasis.     When  the  cornua  come  into 

Central  inclsfon 


Fig.  88. — A  scheme  of  symmetrical  morcellation.  The  segments  are 
removed  as  numbered.  Sometimes  it  will  be  necessary  to  remove  segments 
I,  2,  3,  4  only,  and  this  is  especially  true  in  pus  cases  with  hypertrophy  of  the 
uterus.  But  in  fibroid  cases  the  procedure  will  have  to  be  pursued  so  as  to 
embrace  most  of  the  tissue  included  within  the  dotted  lines. 

view,  if  necessary,  a  large  wedge  is  cut  from  the  fundus, 
the  base  of  which  is  at  the  top  of  the  uterus.  This  piece 
will  encroach  upon  the  posterior  surface  of  the  uterus, 
and  at  once  upon  its  removal  the  cornua  with  their  tubes 


212  PELVIC   INFLAMMATION. 

come  still  further  into  view.  The  grooved  guide  is  now 
inserted  behind  the  uterus  and  the  organ  spUt  in  two 
parts.  The  further  steps  of  tlie  operation  are  described 
under  Hemisection,  third  and  fourth  stages.  In  reahty 
morcellation  is  not  a  very  important  factor  in  the  removal 
of  inflamed  uteri.  In  fibroid  extirpation  it  is  an  invalu- 
able essential.  In  these  pus  cases  the  morcellation  is  use- 
ful only  as  a  step  preliminary  to  hemisection.  Without 
it  in  certain  cases  hemisection  is  difficult.  If  there  be 
absolute  fixity  of  the  cervix,  such  as  we  see  in  bilateral 
broad  liganient  abscess,  it  will  be  necessary  to  secure  the 
uterine  arteries  and  cut  the  cervix  loose  at  the  sides  be- 
fore beginning  with  the  hemisection  and  morcellation; 
but  I  consider  it  a  misfortune  when  I  am  compelled  to 
apply  hemostasis  before  the  adnexa  are  free  (Fig.  89). 

Sometimes  the  operator  will  find  that  even  after  he  has 
removed  all  the  visible  portion  of  the  anterior  uterine 
wall  he  can  not  turn  down  the  cornua  beneath  the  peri- 
cervical  ring.  Either  the  adhesions  above  the  uterus  are 
so  dense  that  the  cornua  are  fixed,  or  else  there  is  a  mass 
behind  the  lower  zone  of  the  uterus  which  prevents  de- 
scent of  the  organ.  When  he  comes  to  a  standstill  in  his 
anterior  morcellation  he  proceeds  as  follows :  The  uter- 
ine arteries  are  clamped  by  two  forceps  and  the  cervix  is 
freed  with  scissors.  The  cervix  is  then  amputated  at  the 
level  of  the  internal  os.  A  firm  grasp  is  taken  of  the 
stumps,  and  the  posterior  uterine  wall  is  morcellated  as 
was  the  anterior.  After  proceeding  half  way  up  the 
uterus  in  this  manner  it  may  often  be  found  that  the 
uterus  is  so  shelled  out  that  it  may  be  partially  inverted, 
or  that  one  cornu  may  be  brought  so  far  into  view  that 
forceps  may  be  applied  to  the  ovarian  artery  close  to  the 
cornu.  If  this  can  be  done  it  is  an  easy  matter  to  cut 
the  uterus  loose  upon  one  side  and  to  swing  the  muti- 
lated organ  out  of  the  vagina.  The  enucleation  of  the 
adnexa  attached  to  this  large  portion  of  the  uterus  is 
then  made  as  though  the  uterus  had  been  split  in  half, 
and  it  is  removed  with  the  adnexa  of  that  side  as  in 
hemisection.      Then   the   adnexa   outside    the    forceps 


MORCELLATION. 


213 


which  was  first  placed  on  the  ovarian  artery  of  the  oppo- 
site side  is  freed  and  brought  out;  the  ovarian  artery 
secured  outside  the  ovary  and  the  adnexa  together  with 


g/m .  ~  ^ 


Fig.  89. — Showing  the  effect  of  morcellation  as  outlined  in  Fig.  88.  The 
traction  forceps  draw  tlie  cornua  together  so  that  the  fundus  is  made  to  roll 
out  beneath  the  bladder. 


the  provisional  forceps  are  removed.  By  this  method  of 
irregular  morcellation  very  large  uteri  can  be  taken  out 
through  the  vagina  with  the   use  of  only  four  forceps 


214 


PELVIC   INFLAMMATION. 


(Fig.  90).  All  through  such  an  operation  as  described 
repeated  palpations  nuist  be  made  of  the  arterial  anasto- 
moses at  the  sides  of  the  uterus,  and  the  utmost  care 
must  be  exercised  not  to  wound  them  either  by  scissors 


Fig.  90. — Symmetrical  morcellation  of  the  fibroid  uterus.  The  uterus 
reached  the  level  of  the  umbilicus.  Miss  L.,  aet.  42.  Vaginal  Ablation.  Four 
pairs  forceps  used.     Recovery. 

or  traction  forceps.  I  employ  for  morcellation  very 
stout  scissors  curved  on  the  flat,  one  blade  blunt  and  the 
other  pointed  (Figs,  91  and  92).     The  pointed  blade  can 


Fig.  91. — Sharp   heavy  scissors,  especially  useful    in    morcellation. 
point  can  be  driven  into  the  tissues,  however  hard. 


Either 


be  driven  into  the  tissue.     I  am  further  careful  always  to 
cut  from  without  in. 

An  assistant  can  lend   material  aid  by  pressing  down 
above  the  pubes,  employing  the  closed  fist  for  this  pur- 


VAGINO-ABDOMINAL  HYSTERECTOMY. 


215 


pose.  Such  support  prevents  the  uterus  being  drawn  up 
in  case  the  traction  forceps  tear  through.  The  operator 
should  strive  to  avoid  lacerating  the  uterine  tissue  by 
pulling  his  traction  forceps  through  it.  This  may  hap- 
pen to  him  once,  but  the  one  experience  should  teach 
him  the  degree  of  traction  the  tissues  will  tolerate  with- 
out tearinpf. 


Fig.  92.—  Stout  blunt  scissors  used  in  vaginal  hysterectomy. 

Like  all  very  technical  manoeuvres  pages  of  descrip- 
tion of  the  various  steps  do  not  become  mental  pictures 
until  applied.  But  one  operation  upon  a  difficult  case 
will  suffice  to  make  clear  the  necessity  for  all  I  have 
written.  If  the  operator  meets  fibroid  nodules  within  the 
uterine  walls  they  are  shelled  out  of  their  beds.  The 
removal  of  each  of  such  isolated  growths  aids  in  the 
progress  of  the  operation. 


VAGINO-ABDOMINAL  HYSTERECTOMY  IN 
THE  PUERPERAL  STATE, 

Indications. — It  is  supposed  that  a  possible  malarial 
paroxysm  has  been  eliminated  by  cinchonizing  the 
patient  by  means  of  a  rectal  injection  of  quinin  solution 
(see  formulae).  Faithful  trial  of  intra-uterine  irrigations 
(see  septic  endometritis)  have  failed  to  subdue  the  symp- 
toms of  septicemia,  and  the  operator  determines  to  open 
the  posterior  cul-de-sac.  This  he  does  after  per- 
forming curettage.  When  the  cul-de-sac  is  open 
the  propriety  of  performing  hysterectomy  may  be  set- 
tled, but  it   is  impossible  before.     Upon  inspecting  the 


2x6  PELVIC  INFLAMMATION. 

uterus  it  is  fouMcl  livid  and  usually  studded  with  isolated 
flakes  of  lymph.  The  curettage  has  shown  the  inside  of 
the  uterus  to  be  necrotic,  and  after  the  cul-de-sac  is 
opened  slight  pressure  with  the  examining  finger  will 
break  the  uterine  wall.  The  uterus  is  in  a  necrotic  con- 
dition. The  fluid  evacuated  from  the  cul-de-sac  may  be 
muddy  serum  containing  more  or  less  lymph,  or  sero- 
pus  may  be  present  in  large  quantities  lying  free  in  the 
pelvic  cavity.  Almost  any  one  of  the  various  lesions  of 
the  ovaries  and  tubes  may  be  found.  But  the  indica- 
tions for  ablation  are  the  necrotic  or  gangrenous  condi- 
tion of  the  uterine  walls,  and  a  septicemia  which  will  not 
yield  to  curettage  and  cul-de-sac  evacuation.  The  pres- 
ence of  pus  in  the  pelvis  with  a  firm  uterus  does  not  call 
for  ablation.  A  sufificiently  effective  evacuative  opera- 
tion can  be  made  through  the  cul-de-sac  without  remov- 
ing the  uterus;  and  the  presence  of  enormous  amounts 
of  recent  lymph  not  only  does  not  call  for  the  ablation, 
but  rather  contra-indicates  it,  if  the  uterus  be  firm.  If 
by  bacteriological  examination  of  the  discharge  strepto- 
cocci have  been  found,  this  is  but  another  reason  for  has- 
tening ^le  operation.  I  wish  to  be  clearly  understood  as 
opposed  to  this  formidable  operation  for  septicemia 
where  there  is  absence  of  signs  of  uterine  necrosis. 
Streptococci  may  be  present  and  large  quantities  of  pus 
produced,  and  yet  the  cul-de-sac  evacuation  will  suffice 
to  effect  a  cure.  If  the  uterus  is  beyond  saving,  so  long 
as  it  remains  it  feeds  the  lymphatics  with  septic  material. 
These  women  die,  not  from  the  peritonitis  and  pus  foci, 
but  from  septicemia. 

Operation. — Rapidity  in  operating  is  essential.  The 
uterus  is  curetted,  irrigated,  and  packed  with  gauze. 
The  posterior  cul-de-sac  is  opened,  and  the  bladder  is 
partially  separated  from  the  cervix  by  incising  the  vagi- 
nal mucous  membrane.  Into  the  posterior  incision  iodo- 
form gauze  is  stuffed.  While  he  cleanses  his  hands,  the 
operator  has  the  patient  placed  in  Trendelenburg's  posi- 
tion and  prepared  for  laparotomy.  The  abdomen  is  opened 
from  the  umbilicus  to  the  pubis.      As  soon  as  it  is  entered 


VAGINO-ABDOMINAL  HYSTERECTOMY. 


2T7 


the  intestines  are  gently  brought  above  the  pelvic  brin. 
and  held  there  by  large  gauze  pads.  Stout  hysterectomy 
forceps  are  made  to  clamp  the  broad  ligaments  outside 
the  ovaries,  and  the  broad  ligaments  are  severed  internal 
to  and  alongside  the  forceps.  Smaller  forceps  secure 
the  spouting  ovarian  arteries  at  the  sides  of  the  uterus. 
The  operator  then  lifts  the  uterus  up  and  draws  out  the 
plug  of  gauze  in  the  posterior  cul-de-sac.  He  inserts 
two  fingers  into  the  vaginal  opening,  so  as  to  hold  the 
uterus  in  the  palm  of  his  hand,  and  hooks  his  fingers  in 
the  vagina  in  front  of  the  cervix.  Upon  these  as  a  guide 
he  strips  the  bladder  from  the  anterior  face  of  the  cervix. 
This  is  done  by  first  making  an  incision  through  the  per- 
itoneum at  the  uterovesical  fold  which  extends  across  the 
face  of  the  uterus,  and  then  by  means  of  the  fingers  of 
the  right  hand  literally  rubbing  the  bladder  tissues  away 
from  the  uterus.  As  the  anterior  vaginal  wall  was  incised 
at  the  time  the  curettage  was  done,  it  is  easy  to  dissect 
the  bladder  from  the  uterus.  Two  pairs  of  forceps  which 
are.  inserted  alongside  the  uterus  are  made  to  grasp  the 
central  portions  of  the  broad  ligaments.  The  ligaments 
are  cut  to  near  their  points.  Two  other  forceps  are  made 
to  grasp  all  the  remaining  tissues  at  the  sides  of  the  cer- 
vix. These  last  forceps  secure  the  uterine  arteries,  and 
their  points  project  into  the  vagina.  The  uterus  is  then  re- 
moved. The  pelvis  is  wiped  dry,  and  the  vagina  is  packed 
with  gauze  from  above.  The  six  forceps  are  lifted  up  in 
a  bunch  and  are  carefully  surrounded  by  iodoform  gauze 
strips,  which  project  above  the  skin  of  the  abdomen.  At 
no  point  must  the  forceps  touch  the  pelvic  floor  or  lateral 
pelvic  walls.  They  will  produce  slough  wherever  they 
rest.  The  pelvic  dressing  is  very  large,  the  pelvis  being 
completely  filled  with  gauze.  A  few  stout  silver  wire 
sutures  are  passed  so  as  to  approximate  the  peritoneal, 
fascial,  and  muscular  planes  around  the  gauze.  The  ab- 
domen is  dressed  in  such  a  way  that  no  pressure  can  be 
brought  upon  the  forceps.  This  is  most  important.  Into 
the  elbow  vein  from  thirty  to  ninety  ounces  of  normal 
salt  solution  are  injected.     If  the  patient  lives,  the  forceps 


2i8  PELVIC    INFLAMMATION. 

are  removed  in  forty-eight  (48)  hours.  Under  chloroform 
all  dressings  are  changed  in  one  week,  great  care  being 
exercised  to  fill  the  pelvis.  In  doing  this  the  intestines 
are  held  back  by  retractors,  and  as  a  soiled- strip  of  gauze 
is  removed,  a  clean  one  is  inserted.  The  intestines  must 
not  be  allowed  to  leak  down  into  the  pelvis.  After  re- 
moving the  abdominal  dressings,  the  patient  is  placed  in 
the  lithotomy  position  and  the  vaginal  dressings  are  re- 
newed. Other  dressings  are  made  as  indicated.  The 
outpouring  of  serum  at  first  is  enormous.  After  the  first 
dressing  the  production  of  pus  is  pronounced.  It  is  dirty 
surgery,  but  it  is  life-saving.  To  use  ligatures  is  to  make 
sinuses  even  if  the  ligatures  hold  in  the  rotten  tissues. 
To  close  the  belly  is  to  lose  the  patient.  Not  alone  the 
uterus,  but  all  the  retroperitoneal  tissues  are  infected, 
and  provision  must  be  made  for  the  escape  of  their  septic 
contents.  The  gauze  is  not  used  alone  for  drainage,  but 
to  isolate  the  entire  pelvis.  Iodoform  poisoning  may 
occur,  but  it  is  a  risk  which  must  be  encountered.  To 
save  even  fifty  per  cent,  of  these  women  is  a  triumph,.for 
all  would  die  without  the  operation.  Those  which  have 
died  were  those  in  whom  the  tedious  ligature  operation 
was  done  and  the  belly  closed.  It  will  be  noticed  that 
both  pelvic  and  abdominal  Mikulicz  dressings  are  made. 
The  general  treatment  is  important.  Hypodermics  of 
strychnin,  gr.  zt>,  are  given  q.  3  h.  for  a  day  and  then 
diminished  gradually.  If  the  kid)ieys  are  damaged,  glo- 
noin,  gr.  tuo,  hypodermically,  is  given  q.  3  h.  or  as  often 
as  needed,  and  the  day  after  the  operation  another  intra- 
venous injection  of  salt  solution  is  made  without  narcosis. 
Having  met  and  cured  the  most  desperate  cases  of  puer- 
peral fever  at  all  stages  of  the  disease,  I  am  warranted  in 
advising  this  radical  work  where  irrigation,  curettage, 
and  cul-de-sac  evacuation  fail.  I  cannot  sit  by  and  fill  a 
woman's  stomach  and  skin  with  drugs  when  I  know  that 
she  holds  within  her  body  a  rotten  mass  filled  with 
myriads  of  germs  each  reproducing  millions  a  day. 
These  cases  of  puerperal  "fever  energetically  treated  as 
soon  as  seen,  will  rarely  die.      Only  those  vicious  infec- 


AFTER-TREATMENT   OF   HYSTERECTOMY. 


219 


tions,  as  gangrene  of  the  uterus  and  thrombophlebitis, 
will  resist  the  irrigation,  or  the  curettage  and  cul-de-sac 
incision.  Fortunately  such  cases  are  rare,  but  when  met 
with  hysterectomy  ,alone  will  save  them.  Too  many 
hundreds  of  women  die  in  America  every  year  because 
the  let-alone  policy  is  adopted.  The  higher  the  authority 
— speaking  against  the  surgical  treatment  of  this  essen- 
tially surgical  disease — the  greater  the  mischief,  for  weak 
brothers  applaud  high  authorities  when  they  preach  inac- 
tivity. But  I  desiie  to  utter  a  warning  against  the  appli- 
cation of  this  operation  in  cases  which  do  not  strictly 
demand  it.  It  is  in  those  sudden  virulent  infections  due 
to  streptococci  that  I  have  practiced  this  operation.  Such 
a  case  will  from  the  first  carry  a  temperature  rarely  below 
103°  and  a  pulse  more  often  above  than  below  130.  And, 
as  I  have  said  above,  the  curettage  and  examination  of 
the  uterus  through  the  cul-de-sac  will  demonstrate  that 
the  soft,  flabby,  friable,  and  discolored  uterus  is  in  a  con^ 
dition  of  cellular  disintegration.  If  even  the  most  viru- 
lent infections  are  treated  surgically  from  the  first,  it  is 
doubtful  if  a  hysterectomy  will  be  required.  It  is  in  the 
early  application  of  the  curettage  and  cul-de-sac  opera- 
tion in  those  cases  which  do  not  yield  to  intra-uterine 
irrigations  that  we  must  find  a  substitute  to  hysterectomy, 
or  rather  a  means  to  render  it  unnecessary. 


AFTER-TREATMENT  OF   HYSTERECTOMY 
AND  VAGINAL  SECTION, 

General. — If  the  patient  has  been  properly  prepared 
for  the  operation,  I  give  absolutely  no  drink  or  nourish- 
ment for  six  hours  after  the  operation.  In  debilitated 
women  and  those  profoundly  septic,  it  is  advisable  to 
administer  fluids  at  this  time.  I  give  one  ounce  of  cold 
sterile  water  with  five  drops  of  lemon  juice  every  hour. 
As  a  rule,  this  will  allay  vomiting,  and,  in  those  women 
who  have  regurgitation  of  bile  into  the  stomach  (green 
vomit),  this  is  particularly  useful.     The  acidulated  water 


2  20  PELVIC   INFr.AMMATION. 

tends  to  check  the  vomiting,  and  seems  to  cause  the  bile 
to  flow  in  the  right  direction.  At  any  rate,  these  cases 
often  have  several  bile-stained  stools  in  twelve  hours 
after  the  administration  of  the  acidulated  water  is  begun. 
But  my  general  rule  is  to  keep  the  stomach  perfectly 
empty  for  twelve  hours,  and  then  begin  the  administra- 
tion of  either  rubinat  or  apenta  water.  This  is  given  in 
half  ounce  quantities,  each  dose  being  followed  by  a  half 
ounce  of  sterile  water.  This  is  administered  every  hour, 
until  six  ounces  are  taken.  Two  hours  after  the  last 
dose  a  small  enema  is  given  composed  of  a  half  ounce  of 
glycerin  and  five  ounces  of  water.  In  those  cases  which 
have  green  (bile)  vomit  I  do  not  give  salines  until  all 
vomiting  ceases.  Women  with  alcoholic  stomachs  who 
vomit  even  in  spite  of  the  acidulated  water  must  be  given 
a  little  iced  champagne,  about  one  ounce  an  hour.  The 
entire  object  of  the  first  after-treatment  is  to  get  the 
bowels  open,  and,  at  the  same  time,  to  prepare  the 
stomach  for  the  reception  of  food.  After  the  bowels 
have  operated,  I  give  a  half  ounce  of  hot  chicken  broth, 
every  hour  or  so,  for  the  first  day,  with  a  bite  or  two  of 
toast  occasionally.  The  third  day  I  allow  coffee  and 
toast  in  the  morning,  four  ounces  of  broth  and  toast 
at  eleven,  scraped  beef  at  two,  more  broth  at  five.  Be- 
tween the  feedings  I  give  abundance  of  water.  Grad- 
ually the  patient  gets  upon  regular  diet,  with  the  excep- 
tion of  fruits  and  vegetables.  These  I  do  not  allow  until 
after  the  first  dressing.  The  third  night  after  the  opera- 
tion, 1  generally  give  one  compound  rhubarb  pill,  fol- 
lowed next  day  by  a  small  enema.  After  the  first  dress- 
ing, I  give  cooked  fruits,  meat,  soups,  potatoes,  rice, 
simple  puddings.  But  all  the  time,  abundance  of  water. 
I  never  give  milk.  During  convalescence  cream  and 
oatmeal  or  hominy  are  allowed.  The  prepared  foods  in 
the  market  are  useful  for  rectal  injection  only,  where  the 
stomach  refuses  to  retain  anything. 

Catlietor. — Every  two  hours  after  operation,  the  self- 
retaining  catheter  is  opened  and  the  quantity  of  urine 
escaping   is   measured.     A  specimen  is    analyzed.     On 


AFTER-TREATMENT   OF    HYSTERECTOMY.  221 

the  second  clay  the  bladder  is  washed  out  with  saturated 
solution  of  boric  acid,  and  the  catheter  is  withdrawn. 
The  urine  is  drawn  every  four  hours  after  this.  Some- 
times the  bladder  leaks  around  the  stationary  catheter, 
puzzling  the  inexperienced. 

Anodynes. — These  I  never  use  except  with  epileptics. 
Then  I  give  a  little  morphin.  Cavity  work  and  morphin 
are  incompatible.  The  pain  is  pretty  severe.  It  is  a  new 
kind  of  pain  to  the  woman,  but  is  easily  endurable.  Any 
relief  obtained  from  the  use  of  morphin  is  but  temporary; 
it  is  borrowed.  It  must  be  paid  back  later  in  vomiting, 
tympanites,  repeated  enemata,  etc.  After  the  bowels 
operate  the  patients  are  quiet.  Usually  five  hours  of 
refreshing  sleep  are  obtained  the  second  night.  The 
sick-room  is  to  be  kept  quiet,  no  visitors  being  admitted  ; 
particularly  none  of  the  family,  until  the  patient  is  out 
of  danger,  on  the  fourth  day.  In  operating  in  private,  if 
the  surroundings  are  controlled  as  they  are  in  hospitals, 
the  results  will  be  the  same.  After  operations  on 
women  who  have  the  opium  habit  I  give  hypodermically 
morphin  gr.  |  and  hyoscyamin  gr.  t^o.  It  is  seldom 
necessary  to  repeat  this. 

Position  of  Patient. — This  is  generally  dorsal,  the 
knees  drawn  up  and  supported  on  a  hard  pillow.  After 
the  forceps  are  removed*  the  patient  is  kept  on  the  back 
for  six  hours  longer,  so  as  not  to  cause  bleeding  by 
moving,  and  after  this  time  she  is  allowed  to  turn  on 
her  side. 

Removal  of  Forceps. — This  is  done  at  the  end  of  forty- 
eight  hours.  Selecting  the  lowest  forceps,  the  keys  are 
applied  and  the  forceps  unlocked.  The  catch  is  sepa- 
rated one-quarter  inch.  The  operator  will  now  appre- 
ciate the  importance  of  having  his  forceps  all  made  alike, 
for  the  separation  at  the  lock  will  tell  him  the  distance 
between  the  points  which  are  hidden  within  the  patient's 
body.  The  keys  are  removed  and  the  forceps  is  twisted 
about  10°  one  way,  held  in  that  position  a  moment  and 
then  twisted  10°  in  the  opposite  direction.  Usually 
this  will_suffice_to  loosen  the  stump  from  the  forceps. 


2  22  PELVIC   INFLAMMATION. 

While  twisting  the  forceps  back  and  forth  gentle  traction 
is  made  upon  the  instrument.  No  force  must  be  used. 
If  the  forceps  does  not  slip  out  readily,  either  the  stumps 
are  stuck  to  it  and  must  be  freed  by  repeated  twisting  of 
the  instrument,  or  else  the  gauze  has  become  stuck  to 
the  forceps  and  must  be  liberated  by  introducing  a  blunt, 
flat  instrument  of  some  sort  between  the  gauze  and  the 
forceps.     In  this  manner  each  forceps  is  removed. 

Time  in  Bed. — Cases  of  cul-de-sac  exploration  and 
replacement  are  allowed  out  of  bed  after  the  third  dress- 
ing. This  is  true  also  of  hysterectomy  cases,  unless  the 
vagina  be  widely  opened  and  the  perineum  gaping.  In- 
asmuch as  the  third  dressing  is  usually  made  on  the 
seventeenth  day,  the  patients  are  out  of  bed  generally  be- 
fore the  expiration  of  three  weeks.  I  make  no  attempt 
to  hasten  their  discharge,  but  allow  the  surfaces  to  heal 
without  much  physical  effort  by  them,  and  their  minds 
to  recover  from  the  disturbance  incident  to  facing  and 
enduring  so  serious  an  operation. 

Dressings. — In  hysterectomy  cases,  on  the  eighth  day, 
I  put  the  patient  in  Sims'  position.  While  the  woman  is 
in  this  position  and  perfectly  still  a  careful  removal  and 
renewal  of  the  dressings  are  made.  In  removing  the 
gauze  strips  the  centre  ones  are  first  taken  out,  so  as  to 
loosen  those  next  the  vessels.  At  the  top  of  the  cavity 
will  be  seen  the  lymph-covered  rectum  red  and  oozing, 
and  upon  each  side  the  dead  stumps  already  beginning 
to  blacken.  The  instruments  used  in  this  first  dressing 
are  a  long-bladed  Sims'  speculum,  my  trowel  depressor, 
and  a  dressing  forceps.  Sims'  tampon  screw  is  a  valua- 
ble instrument  in  all  these  dressings.  The  second  dress- 
ing is  made  a  week  later. 

The  method  of  dressing  cul-de-sac  and  replacement 
eases  is  described  under  the  proper  chapter. 

Behaviour  of  the  Wounrt. — The  sloughs  produced 
by  the  forcipressure  smell  badly.  There  are  two  ways 
of  removing  this  :  one  by  douching,  after  the  first  dress- 
ings are  removed ;  the  other,  by  ample,  repeated  dress- 
ings.    I  prefer  the  latter.     There  is  no  odor  about  my 


ACCIDENTS   AND   COMPLICATIONS.  223 

patients,  although  I  do  not  dress  them  more  often  than 
once  in  a  week.  The  sloughs  are  blackened  shreds  and 
masses  at  each  side  of  the  vaginal  incision.  They 
should  not  be  pulled  off,  but  should  be  allowed  to  sepa- 
rate gradually.  Healing  does  not  really  begin  until  the 
sloughs  have  separated,  after  which  it  is  very  rapid.  I 
renew  the  dressings  whenever  discharges  escape  through 
them,  and  prefer  Sims'  position  in  doing  this. 

Sometimes  in  healing  there  will  be  produced  at  the 
vault  of  the  vagina  a  knob  of  granulation  tissue.  It  is 
better  not  to  make  application  to  this,  but  to  pull  it  off 
with  Luer's  forceps. 

Occasionally  gonorrheal  urethritis  is  aggravated,  and 
a  coincident  cystitis  induced  by  the  operation  and  cathe- 
terism.  Repeated  irrigations  of  the  bladder  by  saturated 
boric  acid  solution  will  correct  the  latter,  and  silver 
nitrate,  grs.  v.  to  fs'i  once  a  day,  will  cure  the  former. 


ACCIDENTS  AND  COMPLICATIONS. 

Bladder. — The  bladder  is  wounded  more  often  than 
any  other  viscus.  There  are  two  ways  in  which  the 
bladder  may  be  injured.  In  the  digital  separation  of  the 
bladder  from  the  uterus,  the  finger  may  enter  the  blad- 
der cavity.  Carelessness  in  making  the  separation  be- 
tween the  two  viscera  leads  to  this.  The  rent  is  usually 
transverse.  Upon  suspecting  such  an  injury  the  cathe- 
ter is  passed,  and  if  the  mucosa  vesicae  is  even  bruised 
bloody  urine  will  be  withdrawn.  Further  dissection  is 
effected  by  the  use  of  mouse-tooth  forceps  and  scissors, 
as  manual  violence  will  but  enlarge  the  opening.  Trans- 
verse rents  in  the  bladder  do  not  require  suture,  as  they 
close  if  the  bladder  is  kept  empty. 

In  that  method  of  separating  the  bladder  from  the 
uterus  which  is  accomplished  by  progressively  dividing 
the  anterior  uterine  wall  and  dissecting  away  the  bladder 
in  stages,  a  vertical  rent  may  be  made  by  the  scissors. 
The  contracting  bladder  tends  to  keep  such  an  opening 


2  24  TELVIC   INFLAMMATION. 

permanent.  Here,  therefore,  continuous  sutures  of  fine 
chromicised  catgut  should  be  employed  to  close  the 
rent  and  the  bladder  should  be  kept  empty.  The  after- 
treatment  is  modified  by  this  accident  in  but  one  parti- 
cular, namely,  that  the  bladder  should  not  be  allowed  to 
distend.  The  catheter  is  left  in  place  a  week  and  is 
opened  every  hour.  Each  day  the  bladder  is  irrigated 
with  a  saturated  solution  of  boric  acid,  but  at  one  time 
no  more  than  an  ounce  of  the  solution  is  to  be  injected. 
After  the  stationary  catheter  is  removed,  cathetcrism  is 
done  every  two  hours  and  the  intervals  progressively 
lengthened.  The  nurse  should  be  instructed  to  notify 
the  attending  surgeon  if  no  urine  flows,  for  clots  may 
block  the  catheter.  The  injection  of  a  little  boric  acid 
solution  will  clear  the  tube. 

The  rubber  catheter  may  be  pressed  so  snugly  against 
the  pubes  that  flow  of  urine  through  it  will  be  stopped. 
This  condition  will  be  differentiated  from  stoppage  due 
to  clot  by  rotating  the  catheter  and  pushing  it  up  a  half 
inch.  If  it  be  pressure  obstruction  the  urine  will  then 
flow. 

Bowel  Wounds. — I  have  never  wounded  the  gut. 
But  in  several  cases  I  have  found  pus  tubes  opening 
into  the  rectum.  After  the  operation  of  ablation  is  com- 
pleted a  continuous  suture  of  fine  chromic  catgut  closes 
the  bowel  opening.  These  openings  also  tend  to  close 
spontaneously,  and  even  an  awkward  method  of  suturing 
will  be  effective.  The  rectum  should  be  rendered  incon- 
tinent in  these  cases  by  paralyzing  or  dividing  the 
sphincter  ani. 

If  the  pus  sac  opens  into  a  coil  of  small  gut,  or  this 
latter  be  wounded,  the  rules  governing  the  treatment  of 
this  accident  during  laparotomy  will  apply  here.  If  re- 
section is  to  be  done  the  attempt  should  be  made  to  use 
Murphy's  button,  but  the  general  rule  is  that  laparotomy 
and  careful  suturing  are  needed  to  properly  close  wounds 
in  the  small  gut. 

AVoiinds  of  the  Ureter. — These  are  not  recognized 
when   made.     In  fact,  ureteral  fistulae  commonly  occur 


ACCIDENTS   AND   COMPLICATIONS. 


225 


late  as  the  result  of  sloughing  produced  by  improperly 
protected  forceps.  As  the  lower  half  of  the  pelvic  ureter 
is  nourished  by  vesical  arteries,  when  slough  occurs  it 
commonly  involves  at  least  an  inch  of  the  ureter  if  pro- 
duced by  grasping  the  ureter  in  the  forceps;  and  no  me- 
thod of  anastomosis  can  be  applied  later  on.  If  such  an 
accident  is  detected  during  the  operation,  laparotomy 
should  be  done  at  once  and  the  severed  ends  of  the  ure- 
ter be  either  sutured  or  the  ureter  implanted  into  the 
bladder.  If  the  ureteral  fistula  occurs  during  convales- 
cence, the  case  should  be  let  alone  until  no  lesion  remains 
other  than  an  uretervaginal  fistula.  Then  the  case 
should  be  treated  as  though  the  accident  resulted  from 
laparotomy.  At  first,  attempts  are  made  to  close  the 
fistula  through  the  vagina.  These  usually  fail  and  the 
surgeon  must  resort  to  implantation  into  the  bladder  or 
to  nephrectomy.     This  accident  has  not  befallen  me. 

Pneumonia. — This  occurs  not  infrequently,  as  we 
often  operate  upon  those  with  phthisis  or  influenza.  The 
pneumonia  commonly  develops  on  the  second  day,  and 
is  of  the  lobular  type.  I  look  with  suspicion  upon  every 
rise  in  temperature  on  the  third  day  and  carefully  ex- 
amine the  lungs.  For  this  pneumonitis  catarrhalis — 
usually  due  to  streptococcus — I  give  potassium  iodid 
only,  5  grains  q.  i  h.  to  three  doses ;  stop  three  hours, 
and  then  5  grains  q.  i  h.,  three  doses  as  before.  Until 
resolution  becomes  complete,  I  give  10  grains  a  day.  I 
have  not  seen  a  fatal  result  from  pneumonia  following 
vaginal  ablation.  The  general  treatment  embraces  strych- 
nin hypodermatically  and  other  heart  stimulants  as 
needed.  So  soon  as  possible  the  posture  of  the  patient 
must  be  changed  from  the  dorsal  to  the  lateral,  to  check 
the  tendency  to  hypostatic  congestion. 

Nephritis. — The  method  of  preparing  the  patient  very 
much  lessens  the  liability  to  this  complication.  For 
three  days  after  operating  all  urine  is  measured  and  each 
day  an  analysis  is  made.  Upon  the  appearance  of  symp- 
toms of  nephritis,  I  at  once  give  a  high  saline  enema  of 
three  pints.  If  this  is  retained,  I  shall  expect  to  repeat 
15 


2  26  PELVIC   INFLAMMATION. 

it  in  eight  hours.  I  also  order  large  draughts  of  Buffalo 
Lithia  water  in  hourly  administrations.  In  aggravated 
cases  I  give  glonoin  hypodermatically  and  use  either 
subcutaneous  or  intravenous  injections  of  normal  salt 
solution.  Digitalis  is  indicated  in  cases  properly  de- 
manding it  and  should  be  given  as  infusion  by  the  rectum. 
But  it  is  so  slow  in  its  action  that  the  diluent  normal  salt 
solution  must  be  employed  first. 

Intestinal  Paralysis. — From  the  first  the  vomiting  is 
severe  and  frequently  gets  worse.  Blood  may  be  vomited. 
The  bowels  can  not  be  moved  and  tympanitis  becomes 
marked.  The  temperature  rises,  and  the  pulse  becomes 
quick  and  weak.  The  patient  is  pale,  anxious,  and  in 
great  distress.  Neither  she  nor  the  physician  can  detect 
intestinal  peristalsis.  This  condition  I  have  seen  three 
times,  and  only  in  women  who  had  the  most  firm  and 
extensive  adhesion  of  the  small  gut  to  the  uterus  and 
adnexa,  requiring  careful  dissection  to  remove  them. 

The  stomach  should  be  kept  absolutely  empty.  Once 
every  three  hours  one  pint  of  normal  salt  solution  at  a 
temperature  of  iOO°  should  be  injected  into  the  descend- 
ing colon  through'a  Wales  tube  (Fig.  no). 

Hypodermatically  strychnin  is  indicated,  gr.  so  q.  6  h. 
The  first  fluid  administered  by  mouth  should  be  a  little 
chicken  broth,  but  should  not  be  given  until  the  stomach 
has  been  at  rest  for  twelve  hours.  In  a  severe  case  last- 
ing four  and  a  half  days,  no  food  was  given,  but  the  pa- 
tient was  kept  alive  by  the  salt  solution  enemata  alter- 
nating with  nutrient  enemata.  The  old  treatment  of  at- 
tacking the  stomach  with  cerium,  cocain,  belladonna, 
calomel,  etc.,  is  irrational.  The  stomach  is  normal,  and 
the  vomiting  is  due  to  intestinal  paralysis,  regurgitation 
of  bile  into  the  stomach,  and  reversed  peristalsis.  Mor- 
phia ^ut  aggravates  the  trouble. 

Convnlsions. — Epileptics  and  hystero-epileptics  will 
have  repeated  convulsive  attacks.  These  are  best  con- 
trolled by  very  minute  quantities  of  morphin,  gr.  tV  oc- 
casionally. These  are  the  only  cases  in  which  I  employ 
morphin,  and  it  is  indicated  because  the  seizures  are  due 


SECONDARY    HEMORRHAGE. 


227 


to  the  traumatism  inflicted  upon  the  sympathetic  gangha 
of  the  pelvis. 


SECONDARY  HEMORRHAGE* 

Whenever  large  vessels  in  the  body  are  secured,  either 
in  continuity  of  tissue  or  en  masse,  this  accident  may  fol- 
low; and  the  vaginal  operation  is  no  exception  to  this 
rule.  The  vessels  maybe  perfectly  secure  under  the  for- 
ceps, and  yet  secondary  bleeding  occur  any  hour  between 
the  time  they  are  removed  and  two  weeks  later.  The 
bleeding  usually  springs  from  one  uterine  artery,  and  is 
readily  controlled  by  bilateral  pressure.  (Fig.  93.)  A  narrow 


Fig.  93. — Pean's  Ion 


I  use  two  in  makinc 
packing. 


the  pelvic  Mikulicz 


retractor  is  introduced  through  the  center  of  the  column 
of  gauze,  and  one-half  of  the  gauze — that  upon  the  side 
from  which  the  bleeding  comes — is  pulled  hard  against 
the  lateral  pelvic  wall.  A  similar  retractor  is  entered 
alongside  the  first,  and  the  other  half  of  the  gauze  pulled 
to  one  side.  When  it  is  seen  that  the  pressure  is  suf- 
ficient to  stop  the  bleeding,  the  vaginal  packing  is  in- 
creased by  the  introduction  of  additional  pieces  of  gauze 
between  the  two  retractors.  The  retractor  which  holds 
back  the  gauze  over  the  bleeding  vessel  is  not  to  be 
moved  until  the  dressing  is  complete,  but  the  adjustment 
and  compression  of  all  fresh  pieces  of  gauze  are  effected 


2  28  PELVIC   INFLAMMATION. 

by  means  of  the  opposite  blade.  After  waiting  a  few 
minutes  to  sec  whether  the  bleeding  is  stopped,  the  pa- 
tient is  put  to  bed,  the  foot  of  the  bed  being  elevated. 

If  the  pressure  does  not  control  the  hemorrhage,  the 
patient  is  placed  in  Sims'  position  and  given  chloroform. 
All  dressings  are  removed,  and  the  bleeding  vessel  sought 
for.  Descent  of  the  intestines  is  prevented  by  gauze  pads, 
and  the  bladder  is  sharply  retracted  with  the  trowel, 
while  the  perineum  is  held  back  by  a  Sims'  speculum. 
When  the  spouting  vessel  is  seen,  it  is  grasped  with 
bullet-forceps,  which  take  a  firm  hold  on  the  tissues,  and 
the  stump  is  lifted  away  from  the  vaginal  wall.  It  is 
then  an  easy  matter  to  grasp  the  stump  with  forceps. 
The  vagina  is  to  be  packed  with  iodoform  gauze.  If 
after  searching  carefully  the  bleeding  is  seen  to  come 
from  above  the  vaginal  vault,  and  the  vessel  cannot  be 
found,  the  hemorrhage  springs  from  an  ovarian  artery. 
When  the  operator  is  convinced  that  this  is  the  case,  he 
does  not  attempt  to  secure  the  vessel  through  the  vagina 
with  forceps,  nor  to  compress  it  with  gauze,  but,  after 
packing  the  vagina  with  gauze  to  prevent  descent  of  the 
intestines,  he  throws  the  patient  into  Trendelenburg's 
position  and  opens  the  belly.  When  he  has  found  the 
source  of  the  bleeding,  the  artery  is  tied  with  silk  and 
the  stump  trimmed.  The  same  is  done  with  the  other 
ovarian  artery.  The  ligatures  are  cut  short,  and  the 
pelvis  cleared  of  clots.  The  abdomen  is  closed.  It  is  well 
to  give  a  high  enema  of  three  pints  of  salt  solution  before 
the  patient  leaves  the  table,  or  to  inject  sterile  filtered 
normal  salt  solution  into  a  median  cephalic  vein.  I  have 
seen  this  accident  but  once,  in  one  of  my  earliest  cases. 

If  it  be  found  that  the  bleeding  comes  from  the  azygos 
artery  or  other  vaginal  branch,  it  is  best  secured  bypass- 
ing a  curved  needle  around  it  and  tying  en  masse  with 
silk.  I  can  not  conceive  it  possible  that  so  tortuous 
and  long  a  vessel  as  the  ovarian  artery  can  bleed  after 
its  current  has  been  completely  shut  off  for  two  days. 
It  is  probable  that  the  ovarian  artery  bleeds  because  the 
occlusion  has  been  partial  and  incomplete,  and  after  the 


INTRAVENOUS   INJECTION. 


229 


removal  of  the  forceps  the  blood  stream  bursts  through 
whatever  clot  has  formed  in  the  vessel.  It  is  not  so 
with  the  uterine  artery.  After  this  vessel  is  clamped, 
but  little  of  its  length  remains  between  the  forceps  and 
the  internal  iliac  artery,  and,  consequently,  when  the 
forceps  are  removed  the  end  of  the  artery  feels  the  full 
force  of  the  pressure  from  the  iliac. 

I  can  not  explain  the  very  late  hemorrhage  occasion- 
ally occurring  when  the  patient  is  ready  to  get  up,  ex- 
cept upon  the  hypothesis  that  the  repatency  of  the  artery 
becomes  established.  That  this  does  occur  I  have 
shown.  It  has  been  observed  after  abdominal  hysterec- 
tomy with  ligature,  and  has  heretofore  been  ascribed  to 
bleeding  from  anastomotic  vessels.  It  is  always  from 
the  uterine  artery  or  its  branches,  and  is  easily  checked 
by  forceps  applied  through  the  vagina. 


INTRAVENOUS  INJECTION  OF  NORMAL  SALT 
SOLUTION. 

A  seven-tenths  of  one  per  cent,  solution  of  chemically 
pure  sodium  chlorid  in  soft  water  is  made.  This  is  fil- 
tered into  either  a  Florence 
flask — to  be  found  in  all  drug 
stores — or  else  into  a  perfectly 
clean  agate  kettle.  It  is  then 
boiled  ten  minutes  and  is  cool- 
ed by  placing  on  ice.  The 
solution  is  employed  at  a  tem- 
perature of  105°  F.  The  in- 
fusion apparatus  is  composed 
of  a  twelve-ounce  glass  funnel, 
eight  feet  of  pure  gum  rubber 

tubing  to  fit  this,  and  a  Canula     p-j^,  9^._Transfusion  apparatus. 

(Fig.  94),      The  apparatus  is 

boiled  twenty  minutes  in  plain  water.  The  hand  grasps  the 
arm  above  the  elbow  and  compresses  the  veins.  The 
median  basilic  vein  will  show  running  across  the  bend  of 


230  TELVIC   INFF. ANIMATION. 

the  elbow  from  without  in  (Fig.  95).  Flic  skin  is  drawn 
upward  and  is  incised  carehilly  alongside  the  upper  border 
of  the  vein.  Upon  rolling  the  skin  down  into  position 
the  cut  is  found  to  be  over  the  vein.  The  vein  is  care- 
fully dissected  out  of  its  bed.  The  distal  or  outer  end 
of  the  vein  is  grasped  across  with  an  artery  forceps,  and 
a  half  inch  internal  to  this  the  vein  is  caught  with  mouse- 
tooth  forceps.  While  this  is  being  done  an  assistant 
whose  hands  are  absolutely  clean,  has  filled  the  infusion 
funnel.  This  he  holds  six  feet  above  the  patient.  The 
clothing  in  the  patient's  axilla  has  been  loosened.  The 
operator  severs  the  vein  entirely  across  and  takes  the 
canula  in  his  right  hand  while  holding  the  bleeding  end 
of  the  vein  with  toothed  forceps.  The  saline  solution  is 
allowed  to  flow  against  the  cut  end  of  the  vein  until  the 
solution  feels  warm,  then  the  canula  is  inserted  well  into 
the  vessel ;  at  the  same  time,  the  pressure  on  the  arm  is 
loosed.  The  assistant  watches  the  flow  of  water  from 
the  funnel,  and  warns  the  operator  when  he  is  to  refill  it, 
so  that  the  operator  may  compress  the  tube  and  prevent 
entrance  of  air.  To  avoid  this,  all  the  water  is  not  al- 
lowed to  flow  from  the  funnel  before  refilling.  The  speed 
of  flow  is  about  six  ounces  in  three  minutes,  or  about  a 
quart  in  a  quarter  hour.  Having  introduced  the  desired 
amount  of  fluid,  the  canula  is  withdrawn  and  pressure 
made  around  the  arm.  The  two  ends  of  the  vessel  are 
secured  by  fine  catgut,  and  the  wound  stitched  by  the  same 
material-     Iodoform  gauze  dressing. 

Svibcntaiieous  Injection. — The  material  is  prepared 
as  before.  Opposite  the  angle  of  the  scapula  and  over 
the  margin  of  the  latissimus  dorsi  muscle,  the  skin  is 
cleansed.  A  few  drops  of  cocain  solution  is  injected,  or 
the  skin  is  frozen  with  a  stick  of  ice  dipped  in  salt  and 
applied.  It  is  incised  for  a  quarter  inch.  While  the  edges 
are  held  apart,  the  solution  is  allowed  to  flow  through  the 
canula  until  warm,  and  the  canula  is  plunged  into  the  cel- 
lular tissue  between  the  skin  and  muscle.  Ten  ounces  of 
fluid  are  allowed  to  enter,  when  the  canula  is  withdrawn 
and  a  stitch  of  catgut  used  to  unite  the  surfaces.     lodo- 


Fig  95. — The  superficial  veins  at  the  bend  of  the  elbow  (after  Quain): 
6.  The  median  basilic  vein,  into  vi^hich  intravenous  salt  infusion  is  made.  4. 
Cephalic  vein.  3.  Basilic  vein  2.  Venag  comites  of  the  brachial  artery  x- 
As  these  latter  lie  beneath  the  deep  fascia  of  the  arm,  they  are  not  in  danger  in 
the  operation  of  intravenous  infusion  of  salt  solution.  (The  reader's  attention 
is  called  to  the  fact  that  the  elbow  vein  into  which  the  infusion  is  made  is 
sometimes  the  median  cephalic,  as  the  veins  of  the  elbow  are  not  constant  in 
their  arrangement). 


INSTRUMENTS. 


231 


form  gauze  dressing.  Upon  the  other  side  a  similar  in- 
jection is  made.  As  the  fluid  enters  the  cellular  tissue  a 
large  swelling  appears  which  subsides  in  a  few  minutes. 
The  injection  may  be  repeated  lower  down  in  eight  hours. 
I  have  made  three  such  injections  in  twenty-four  hours  in 
a  desperate  case  of  sepsis,  altogether  sixty  ounces.  If 
the  fluid  is  sterile  and  careful  cleansing  of  skin  and  ap- 
paratus has  been  made,  there  is  no  danger  of  suppuration 
following. 

The  author  has  observed  the  following  immediate 
effects  of  intravenous-  infusion  :  the  temperature  rapidly 
falls  if  it  has  been  high,  and  the  pulse  has  been  seen  to 
come  from  160  to  no  even  during  operation.  In  other 
words,  it  is  a  positive  remedy  for  shock.  Remotely,  the 
amount  of  urine  is  greatly  increased,  the  specific  gravity 
falls,  owing  to  the  dilution,  but  the  actual  amount  of 
urea  excreted  is  increased,  and  albumen,  if  present,  is 
either  markedly  diminished  or  disappears  altogether. 
The  procedure  is  thus  particularly  applicable  to  cases  of 
septicemia  and  hemorrhage.  After  operation  it  is  de- 
manded whenever  the  kidneys  exhibit  evidences  of  sup- 
pression. 


INSTRUMENTS. 

Short  Retractors. — There  should  be  two  of  these — 
ort  narrow,  and  one  broad.  I  like  Jackson's  pattern. 
Iwo  Sims  Specula  (Fig.  96). 

Long-  Retractors. — One  long  Jackson  and  one  Pean 
anterior  retractor;  two  long  narrow  Pean  blades  for 
making  lateral  pressure ;  one  Pryor  Pean  trowel  (Figs. 
97,  98,  99,  100,  lOl). 

Ti-actiou  Instruments.  —  One  Pryor's  intra-uterine 
traction  forceps  to  be  used  during  the  first  stage  of  hys- 
terectomy. Two  bullet  forceps,  strong  and  with  short 
blunt  points.  Four  French  traction,  the  instruments  of 
Pean.     These  have  four  teeth,  and  behind  these    upon 


PELVIC    INFLAMMATION. 


Fig.  96.— Jackson  speculum.      FlG.  97.— The  wide,  long  Jackson  posterior 

retractor. 

each  blade  are  deep  serrations.  It  is  important  that  the 
teeth  look  outward  when  the  instruments  are  open,  so 
as  to  grasp   flat,  hard  surfaces,  as  fibroid  nodules.     The 


Fig. 


-Pc.in's  anterior  retractor.     Useful  also  as  a  perineal  retractor  in 
small  vulvee. 


INSTRUMENTS. 


233 


serrations  enable  the  for- 
ceps to  hold  in  soft  tissue 
through  which  the  teeth 
would  otherwise  tear  (Fig. 
102).  The  short  fenes- 
trated forceps  of  Pean  as- 
sist in  holding  the  ad- 
nexa,  and  for  this  purpose 
Luer's  forceps  are  also 
valuable  (Fig.  103). 

Cutting  Instruments. 
— One  straight  blunt  bis- 
toury for  bisecting  the 
cervix  in  stenosis  (Fig. 
104).  Two  scalpels  with 
good  bellies.  One  Pryor's 
bistoury  hollow-ground, 
so  as  to  be  easily  sharp- 
ened. Four  pairs  of  scis- 
sors, one  Sims  vesico- 
vaginal scissors  (Fig.  105) 
to  trim  ovaries  and  tubes  ;  one  blunt  curved  on  the 
flat  and  short;  one  long,  blunt-pointed;  and  one  long 


Fig.  99. — Pean's  posterior  retractor. 


Fig.  100. — The  author's  narrow  trowel. 

sharp-pointed.     Both  of  the  latter  have  blades   curved 
on  the.  flat. 


Fig.  ioi. — The  author's  wide  trowel.     Used  with  women  who   have  large 

vulvae. 


-.u 


PELVIC    INFLAMMATION. 


The  curettes  are  the  pattern  of  Sims,  and  are  of  three 
sizes. 


Fl(J.  102. — French  traction  forceps.     Without  them  hemiscction  and  niorcel- 
lation  would  be  inost  dilficult. 

The  intra-iitevinc  catheters  are  of  the  Fritsch-Boze- 
nian  pattern,  and  of  four  sizes. 


Fig.  103. — Luer's  polypus  forceps.     The  best  for  holding  the  adnexa. 

As  dressing-  instruments  I  use  Sims'  tampon  screw, 
a  long,  slender  packing  forceps,  Hunter's  sponge-holder 
(Fig.  106),  and   Pryor's  packing  applicator.      Two  stout 


jaHH.PcvtiDr.usaciJ 


Fn;.  104. — Bistoury  for  splitting  the  cervix. 


^^^^^  J.JUN  XihySDER.—i,^.   iJJity   yuuK. 
Fig.  105, — Fine  scissors  for  conservative  work  on  the  adnexa. 


INSTRUMENTS. 


2.35 


pairs  of  mouse-tooth  forceps  are  needed — one  long  and 
one  short. 


Fig.  io6. — Hunter's  forceps.     I  use  these  for  applying  dressings. 

Hemostatic    Forceps. — Four    Sims'    artery    forceps 
(Fig.  107),  eight  pairs  of  Pryor's  hysterectomy  forceps 


Fig.  107. —  Sims's  stout  artery  forceps. 

(Fig.  108).     These  latter  are  strong,  and  have  transverse 
serrations.     The  blades  are  one  and  a  half  inches   long. 


Fig.  108. — The  author's  forceps.     No  handles  are  in  the  way  of  the  patient's 
movement. 

I  use  the  needle-holder  of  Sims,  and  any  stout  half- 
curved  needles  (Fig.  109)  with  bayonet  points.  The 
best  instrument  for  giving  high  enemata  after  operation 


236 


TELVIC    INFLAMMATION. 


is  a'Wales  bougie  (Fig.  1 10).  To  .secure  the  patient's  legs 
I  employ  Ott's  crutch. 


Fig.  109.— Sims's  needle-holder.     The  simplest  and  best. 

l/RS—CO.     NEW   YORK. 

Fig.  no. — Wales  bougie  for  giving  high  saline  injections. 


OPERATING  TABLE. 

I  have  devised  and  for  a  long  time  used  the  one  shown. 
It  can  be  employed  for  any  kind  of  gynecological  work, 
and  is  portable.  (See  Figs.  56,  57,  58.)  Without  it, 
much  of  my  pelvic  work  would  be  most  difficult  and 
tedious.  The  distances  in  America  are  so  great  that 
those  of  us  who  operate  over  the  entire  country  must  go 
prepared  for  any  work.  My  table  is  strong  enough  for 
the  heaviest  woman,  and  weighs  seventy  pounds.  It  is 
dressed  for  the  operation  with  blankets  and  a  rubber 
sheet,  or  piece  of  oil  cloth.  The  shoulder  brace  can 
slide  on  the  table,  so  as  to  support  any  size  of  body. 


FORMULAE. 


237 


FORMULAE. 

Thiersch  Solntiou. — Boric  acid  crystals,  12  parts; 
salicylic  acid  crystals,  2  parts;  water,  looo  parts.  Tab- 
lets to  make  one  quart  are  sold  by  Reeder  Brothers, 
Thirty-first  Street  and  Fourth  Avenue,  New  York. 

Normal  Salt  Solution. — This  is  a  .7  per  cent,  of 
sodium  chlorid  in  water. 

Solution  of  Quinin. — Quin.  sulph.  grs.  xx,  acid  tar- 
taric grs.  xvii,  aquae  oiii-     Give  warm  by  rectum. 

Lysol. — This  is  five  times  as  antiseptic  as  carbolic 
acid,  and  but  one-eighth  as  poisonous.  I  use  it  for  my 
hands  as  a  2  per  cent,  solution,  and  on  the  patient  in  a 
I  per  cent,  solution.  It  soponifies  fat  and  cleanses 
mechanically  as  well  as  chemically. 

Iodoform  Gauze. — The  gauze  is  sterilized.  It  is 
then  dipped  in  a  5  per  cent,  or  10  per  cent,  solution  of 
iodoform,  in  ether,  and  laid  on  a  sterile  sheet  to  dry. 
When  dry,  it  is  blue  and  unfit  for  use.  It  is  now  dipped 
in  a  hot  bichlorid  of  mercury  solution,  i  :  4,000,  when  the 
yellow  color  returns.  It  is  wrung  as  dry  as  possible  and 
packed  in  glass  jars.  The  mouths  of  these  are  stuffed 
with  cotton,  after  which  the  jars  are  inverted  in  a  steam 
sterilizer  and  sterilized  for  an  hour.  The  dressing  is 
expensive,  but  as  it  is  non-poisonous,  and  requires 
renewal  once  where  other  dressings  are  changed  three 
times,  it  is  worth  the  difference.  It  can  be  readily  made 
by  a  careful  nurse  or  assistant.  I  am  using  the  2  per 
cent,  and  5  per  cent,  strengths  more  than  formerly,  and 
find  them  as  good  as  the  stronger. 

Cliicken  Broth. — A  fowl  is  cleaned  and  skinned.  It 
is  chopped  into  pieces,  bones  and  flesh.  These  are  put 
into  three  quarts  of  water,  and  actively  boiled  for  eight 
hours.  As  the  water  evaporates,  the  quantity  is  kept  to 
three  pints  by  adding  boiling  water.     Strain  into  a  clean 


^^s 


PELVIC   INFLAMMATION. 


bowl  and  put  on  ice.  This  jelly  is  heated  when  needed. 
The  flesh  of  fowl  is  the  only  flesh  that  dissolves  in  water. 
This  is  the  first  food  my  patients  get  after  operation. 

Beef  Juice. — The  steak  is  broiled  medium,  chopped 
up  and  squeezed  in  a  press  or  lemon  squeezer.  It  is 
served  warm. 

Xiitrient  Kiienia. — One  raw  egg,  two  ounces  squeezed 
beef  juice,  two  ounces  milk,  one  tube  of  Fairchild's  pep- 
tonizing powder,  warm  to  ioo°.  Give  this  once  in  four 
hours. 


STERILIZATION* 

Tlie  Siirg-eou. — It  is  exceedingly  important  that  the 
operator's  hands  be  technically  clean,  even  in  dealing 
with  pus  cases;  but  it  is  difficult  to  obtain  absolutely 
aseptic  hands.  The  finger  nails  should  be  short.  The 
sleeves  are  rolled  up  to  the  biceps,  and  the  hands  and 
arms  are  scrubbed  with  hot  water  and  soap.  At  least 
five  minutes  should  be  devoted  to  this.  This  will  soften 
the  nail  filth.  A  sterilized  sharp  steel  nail  cleaner  is 
used  to  cleanse  the  nails.  Particular  attention  should  be 
paid  to  the  base  of  the  nails,  as  here  the  loose  epithelium 
is  most  often  found.  Not  only  is  all  dirt  under  and 
behind  the  nails  removed,  but  the  nails  should  be  scraped 
as  well.  They  are  again  scrubbed  with  the  brush.  The 
operator  hollows  his  left  hand  and  fills  it  with  chlorid  of 
lime,  "bleaching  powder."  He  adds  to  this  a  little  water 
and  makes  a  paste  in  his  hand.  Selecting  a  stick  "of  car- 
bonate of  soda,  "  washing  soda,"  he  rubs  this  into  the 
lime  paste,  and  over  his  hands  and  arms.  The  soda  is 
used  much  as  a  cake  of  soap  would  be.  As  he  contin- 
ues the  process,  he  will  notice  that  the  grains  of  lime 
gradually  disappear,  and  when  no  more  grains  are 
present,  he  puts  aside  the  soda,  and  washes  off  the  white 
paste.  By  this  procedure  he  develops  upon  his  hands 
and  arms  nascent  chlorin  gas,  a  most  powerful  disinfec- 
tant.    Both  the  essentials  can  be  procured  at  small  cost 


STERILIZATION. 


239 


anywhere.  After  doing  this,  the  hands  are  almost  cer- 
tainly clean ;  but  I  go  further,  and  scrub  the  nails  and 
hands  in  2  per  cent,  lysol  solution,  after  which  they  are 
rinsed  in  Thiersch  solution.  The  operator  now  puts  on 
a  sterile  gown,  and  is  prepared  to  operate.  While  thus 
preparing  himself,  one  of  his  assistants  who  has  previ- 
ously sterilized  his  hands,  has  been  cleaning  the  patient's 
buttocks  and  vagina.  (Vide  "  Preparation  of  Patient.") 
During  the  operation  the  surgeon  frequently  washes  in 
Thiersch  solution. 

lustriinients. —These  are  boiled  in  5  per  cent,  carbon- 
ate of  soda  solution  for  fifteen  minutes,  the  knives  and 
scissors  being  given  half  this  time.  The  boiling  water 
is  poured  off,  and  the  instruments  allowed  to  cool  or  are 
cooled  by  cold  boiled  water.  No  instrument  pans  are 
used,  but  the  instruments  are  laid  out  upon  a  sterile 
sheet  and  kept  covered  from  dust.  The  boiling  soda 
solution  not  only  sterilizes  them,  but  dissolves  all  fat, 
pus,  and  blood  upon  them.  Chemical  sterilization,  as  by 
formaldehyd  gas,  is  uncertain.  I  usually  boil  the  nail 
scrubs  with  the  instruments. 

Rubber  Goods. — The  rubber  irrigator  (fountain  syr- 
inge) is  half-filled  with  water  and  the  clip  loosened.  It, 
together  with  the  vaginal  brush  and  self-retaining  cathe- 
ter, are  boiled  in  plain  water  fifteen  minutes. 

Irrig-atiiig-  Fluids. — I  use  boiled  normal  salt  solution 
or  boiled  boric  acid  solution  4  per  cent.  But  I  have 
about  abandoned  irrigation  except  to  wash  out  large 
uteri  after  curettage. 

Transfusion  Fluid. — Ordinary  table-salt  is  dissolved 
in  soft  water  to  make  a  tV  of  i  per  cent,  solution.  It  is 
then  filtered  and  boiled  in  a  new  kettle,  the  neck  of  which 
is  plugged  with  cotton.  This  solution  is  cooled  to  about 
105°  F.  In  handling  it,  care  should  be  taken  not  to  agi- 
tate the  contents  of  the  kettle,  lest  sediment  be  put  in 
suspension.  Whenever  there  is  sediment  in  the  solution, 
it  should  be  carefully  strained  through  several  thick- 
nesses of  sterile  plain  gauze  into  the  transfusion  funnel. 
The  gauze  may  be  tied  over  the  spout  of  the  kettle.    This 


240  PELVIC   INFLAMMATION. 

is  an  impromptu  apparatus.  In  my  practice  I  use  chemi- 
cally pure  sodium  chloric!.  The  solution  is  made  and 
filtered  into  a  glass  bottle.  In  this  it  is  boiled.  The 
transfusion  apparatus  is  boiled  for  twenty  minutes  in  plain 
water. 

.Silk,  Silver  Wire,  and  Silkworm  (Jut. — This  is  ren- 
dered sterile  by  boiling  for  seven  minutes  in  5  per  cent, 
carbolic  solution. 

Catgut  and  Kauj»ai-oo  Tendon  cannot  be  prepared 
by  the  surgeon  as  reliably  as  by  several  manufacturers. 
That  made  by  Van  Horn,  Forty-first  Street  and  Fourth 
Avenue,  is  recommended.  » 

Gowns,  Gauze,  Sheets,  Towels. — These  are  subjected 
to  a  continuous  column  of  live  steam  in  a  closed  chamber 
for  at  least  one  hour.  There  are  several  excellent  steri- 
lizers, notably  the  Arnold,  sold  for  a  few  dollars.  If  a 
steam  sterilizer  can  not  be  secured,  the  fabrics  may  be 
boiled  in  plain  water  for  a  half  hour.  Before  using  they 
should  be  wrung  dry.  The  gauze  and  gauze  pads  may 
be  fastened  in  bundles  in  towels,  boiled  and  then  dried  in 
a  not  too  hot  oven. 

Transfusion  solution  and  irrigation  are  so  seldom  re- 
quired, that  the  preparation  for  an  operation  becomes 
very  simple.  Every  physician  should  own  a  steam  steri- 
lizer for  the  preparation  of  his  dressings.  A  very  good 
one  can  be  procured  for  ten  dollars,  just  as  effective  as 
one  costing  hundreds. 

Hand-basins. — These  I  always  boil  in  plain  water. 
Perfect  cleanliness  can  not  be  secured  by  using  basins 
which  have  not  been  sterilized. 


INDEX. 


Abdominal  dressings  in  pelvic  in- 
flammation, 6i. 
Ablation  of  uterus  by  hemisection, 
187. 
dressings  in,  202. 
first  stage,  188. 
fourth  stage,  202. 
second  stage,  193. 
third  stage,  194. 
en  masse,  180. 
vaginal,  163.     See  also  Vagi?ial 
ablation. 
Abortion,  infection  after,  34. 
pelvic  peritonitis  from,  96. 
Abscess  of  broad  ligament,  121. 
symptoms,  122. 
treatment,  123. 
ovarian,  108. 
symptoms,  no. 
treatment,  113. 
Accidents  in  hysterectomy,  166. 
Acute  gonorrheal  endocervicitis, 

25- 

endometritis,  47.     See  Endo- 
metritis. 
salpingitis,   63.     See   Salpin- 
gitis. 
peri-ovaritis,  106. 
treatment,  no. 
salpingo-odphoritis,     conserva- 
tive treatment  of,  152. 
septic    endometritis,    26.      See 

EndoDietritis. 
septic  salpingitis,  69.     See  also 
Salpingitis. 
16 


Adherent    ovaries,    conservative 
treatment  of,  159. 
retropositions,  117- 
operation  for,  118. 
Adhesions,  separation  of,  in  vag- 
inal ablation,  164. 
After-treatment  of  hysterectomy, 

219. 
Analgesia    in  pelvic    peritonitis, 

99. 
Anesthetic,  125. 
Anodynes    in    after-treatment   of 

hysterectomy,  221. 
Apoplexy,  ovarian,  107. 

conservative  treatment  of,  159. 
treatment,  112. 
Appendicitis,  diagnosis  of  pelvic 
inflammation  from,  57. 

B 

Beef  juice,  238. 

Bladder,  wounding  of,  in  vaginal 

ablation,  223. 
Bowel,  wounds  of,  in  vaginal  ab- 
lation, 224. 
Broad-ligament  abscess,  121. 
symptoms,  122. 
treatment,  123. 
cyst,  114. 

conservative  treatment  of,  160. 
symptoms,  115. 
treatment,  116. 

C 

Catgut,  sterilization  of,  240. 
Cervical  polypi,  22. 
treatment,  24. 

241 


24: 


INDEX. 


Csirvix  uteri,  cystic  degeneration 
of,  21. 

treatment,  24. 
polypus  of,  treatment,  24. 
Cliicken  broth,  237. 
Chills  in  pelvic  peritonitis,  loi. 
Chronic     gonorrheal     endocervi- 
citis,  25.    See  Endocervi- 
citis. 
endometritis,  50.     See  Endo- 

Dietritis. 
salpingitis,  72.     See  also  Sal- 
pingilis. 
salpingo-oophoritis,     conserva- 
tive operation  for,  155. 
septic  salpingitis,  72.     See  also 
Salpijigitis. 
Colon  bacillus  as  a  cause  of  pelvic 

peritonitis,  91. 
Conservative  treatment,  146. 

of  acute  salpingo-oophoritis, 

152- 
of  adherent  ovaries,  159. 
of  broad-ligament  cj-sts,  160. 
of    chronic    salpingo-oopho- 
ritis, 155. 
of  cystic  ovaries,  158. 
of  hydrosalpinx,  157. 
of  occluded  tubes,  159 
of  ovarian  apoplexy,  159. 
Constipation   a    cause   of   pelvic 

peritonitis,  96. 
Convulsions  after  vaginal  ablation, 

226. 
Cul-de-sac  operation  in  puerperal 

endometritis,  44. 
Curettage,  126. 
in  puerperal  endometritis,  43. 
instruments  for,  134. 
packing  after,  129. 
repeated  irrigations  in,  133. 


Currettage,  time  for,  130. 
Curette,  Sims',  135. 
Curettes,  234. 
Cyst  of  broad  ligament,  114. 

conservative  treatment,  160. 
symptoms,  115. 
treatment,  116. 
Cystic  degeneration  of  cervix  uteri, 
21. 

treatment,  24. 
of  ovaries,  107. 
ovaries,  T07. 
conservative  treatment  of,  158. 
treatment,  in. 
Cystitis,   diagnosis   of    pelvic    in- 
fiammation  from,  58. 


Diet  in  pelvic  inflammation,  62. 

Diffuse  pelvic  suppuration,  123. 
See  also  Pelvic  suppura- 
tion. 

Digestive  symptoms  in  pelvic 
peritonitis,  loi. 

Douches  in  pelvic  inflammation, 
61. 

Drainage  in.  vaginal  ablation  of 
uterus,  165. 

Dressing  instruments,  234. 
Mikulicz  pelvic,  202. 

Dressings  in   after    treatment   of 
hysterectomy,  222. 
sterilization  of,  240. 


Edematous  ovaritis,  loS. 

treatment,  in. 
Endocervicitis,  acute  septic,  20. 
gonorrheal,  acute,  25. 
diagnosis,  25. 
symptoms,  25. 


INDEX. 


243 


Endocervicitis,  gonorrheal,  acute, 
treatment,  25. 
gonorrheal,  chronic,  25. 
symptoms,  26. 
treatment,  26. 
gonorrheal,    latent.      See    En- 
docervicitis, gonorrheal, 
chronic. 
septic,  diagnosis,  22. 
symptoms,  20. 
treatment,  24. 
Endometritis,  17. 
general  considerations,  17. 
gonorrheal,  acute,  47. 
diagnosis,  48. 
sequelae,  49. 
symptoms,  47. 
treatment,     non-operative, 

48. 
treatment,  operative,  49. 
gonorrheal,  chronic,  50. 
diagnosis,  51. 
symptoms,  50. 
treatment,  51. 
non-virulent,  18. 
puerperal  septic,  35. 
cul-de-sac  operation  in,  44. 
curettage  in,  43. 
irrigation  in,  42. 
septic,  treatment,  41. 
virulent,  18. 
septic,  26. 
acute,  26. 
acute,    differential  diagnosis 

30- 
sequelae,  30. 
symptoms,  26. 
treatment,  30 
tubercular,  52. 
diagnosis,  52. 
sequelae,  53. 


Endometritis,    tubercular,   symp- 
toms, 52. 
treatment,  52. 
Exploratory  vaginal  section,  136. 
advantages  of,  over  abdo- 
minal method,  144. 
Exposure   as   a  cause   of  pelvic 
peritonitis,  96. 

F 

Fluids  in  pelvic  inflammation,  6r. 
Forceps,  French  traction,  234. 

Hunter's,  235. 

Luer's  polypus,  234. 

Pryor's,  235. 

removal  of,  after  hysterectomy, 
221. 

Sims'  artery,  235. 
Formulae,  237. 

French  traction  forceps,  234. 
Fritsch-Bozeman    double-current 
irrigating  tubes,  135. 


Gauze,  iodoform,  237. 
sterilization  of,  240. 

Genital  sclerosis,  26. 

Gonococci  as   a   cause  of  pelvic 
peritonitis,  92. 

Gonorrhea  a  cause  of  pelvic  peri- 
tonitis, 92. 

Gonorrheal  endocervicitis,  acute, 

25- 

endocervicitis,  chronic,  25.    See 
Endocervicitis. 

endocervicitis,  latent,  25. 

endometritis,  acute,   47.       See 
E?idometritis. 
chronic,   50.      See   Endome- 
tritis. 

peritonitis,  92. 


!44 


INDEX. 


Gonorrheal  salpingitis,  acute,  63. 
See  also  Scj/J>i>/,i;;i/is. 
chronic,  72.    See  also  Salpin- 
gifts. 

H 
Hand-basins,  sterilization  of,  240. 
Heart  in  pelvic  peritonitis,  loi. 
Hemorrhage,  secondary,  after  va- 
ginal ablation,  227. 
Hemostasis  in  vaginal  ablation  of 

uterus,  165. 
Hemostatic  forceps,  235. 
Hernia  after  hysterectomj',  166. 
Hunter's  sponge  forceps,  235. 
Hydrosalpinx,  80. 
conservative  operation  for,  157. 
treatment.  So. 
Hysterectomy,  vaginal,  163.     See 
Vaginal  Ablation. 
after  treatment  of,  219. 
anodynes  in  after-treatment  of, 

221 
behavior  of  wound  after,  222. 
removal  of  forceps  after,  221. 
vagi  no-abdominal,  in  puerperal 
state,  215. 

I 

Infection,  puerperal,  34. 
Inflammation,  intra-uterine.     See 
Endonietritis. 
of  ovaries,  106. 

pelvic,  54.     See  Pelvic  I)ifla>n- 
mation. 
Instruments,  231. 

sterilization  of,  239. 
Intestinal  paralysis  after  vaginal 

ablation,  226. 
Intra-uterine  catheters,  234. 
Intra-venous  injection  of  normal 
salt  solution,  229. 


Iodoform  gauze,  237. 
Irrigating  fluids,  239. 
Irrigation   of  uterus   after  curet- 
tage, 129. 
puerperal  endometritis,  42. 
Irrigations,  repeated,  133. 

J 

Jackson's  speculum,  134, 

i  ^ 

Kangaroo  tendon,  sterilization  of, 

240. 

Kidneys  in  pelvic  peritonitis,  loi. 

L 

Latent  gonorrheal  endocervicitis, 
25.      See  Endocervicitis. 

Local  applications  in  pelvic  in- 
flammation, 62. 

Luer's  polypus  forceps,  234. 

Lungs  in  pelvic  peritonitis,  loi. 

Lysol,  237. 

M 

Mikulicz  pelvic  dressing,  202. 
Morcellation,  209. 

N 
Nephritis  after  vaginal  ablation, 

225. 
Non-purulent  endometritis,  18. 
Normal  salt  solution,  237. 

intra-venous    injection    of, 

229. 
subcutaneous   injection  of, 
230. 
Nutrient  enema,  23S. 

O 

Occluded      tubes,     conservative 

treatment,  159. 
Operating  table,  236. 


INDEX. 


245 


Operator,  sterilization  of,  238. 
Opiates   in   pelvic   inflammation, 

60. 
Ovarian  abscess,  108. 
symptoms,  no. 
treatment,  113. 
apoplexy,  107. 

conservative    treatment     of, 

159- 
treatment,  112. 
sclerosis,  107. 
treatment,  in. 
Ovaries,    adherent,    conservative 
treatment,  159. 
cystic,  107. 
conservative  treatment,  158. 
treatment,  in. 
cystic  degeneration  of,  107. 
inflammatory  diseases  of,  106. 
Ovaritis,  acute,  106. 
edematous,  108. 
treatment,  in. 
symptoms,  109. 


Pachysalpingitis,  72,  74. 

treatment  of,  79. 
Packing  applicator,  Pryor's,  135. 
Packing  of  uterus  after  curetting, 

129. 
Pain  in  pelvic  peritonitis,  99. 
P^an  retractor,  140,  231,  232. 

long  retractor,  227. 
Pelvic  inflammation,  54. 

abdominal  dressings  in,  61. 

diagnosis,  57. 

diagnosis  from  appendicitis, 

57- _ 
diagnosis  from  cystitis,  58. 
diagnosis  from  general  sup- 
purative peritonitis,  59. 


Pelvic     inflammation,     diagnosis 
from  suppurating  ovarian 
cyst,  58. 
diagnosis  from  ureteritis,  58. 
diet  in,  62. 
fluids  in,  61. 
douches  in,  61. 
intestinal  cleanliness  in,  60. 
local  applications  in,  62. 
opiates  in,  60. 
treatment,  62. 
Mikulicz  dressing,  202. 
peritonitis,  90. 
analgesia  in,  99. 
causes,  91. 
chills  in,  loi. 
colon  bacillus  in,  91. 
diagnosis,  102. 
digestive  symptoms  in,  loi. 
gonococci  in,  92. 
heart  in,  loi. 
kidneys  in,  loi. 
lungs  in,  loi. 
pain  in,  99. 
prognosis,  102. 
pulse  in,  100. 
staphylococci  in,  92. 
streptococci  in,  94. 
suppurative,  treatment,  103. 
symptoms,  96. 
temperature  in,  100. 
treatment,  103. 
tubercular,  104. 

symptoms,  105. 

treatment,  105. 
tympanites  in,  99. 
suppuration,  diflfuse,  123. 

symptoms,  124. 

treatment,  124. 
Peri-ovaritis,  acute,  106. 
symptoms,  no. 


-46 


INDEX. 


Peri-.ovaritis,  treatment,  no. 
Peritonitis,  pelvic,  90. 
causes,  91. 
diagnosis,  102. 
prognosis,  102. 
symptoms,  96. 
treatment,  103. 
tubercular,  104. 
symptoms,  105. 
treatment,  105. 
primary  purulent,  94. 
Pneumonia  after  vaginal  ablation, 

225. 
Polypus  of  cervix  uteri,  22. 

treatment,  24. 
Pryor-P^an  trowel,  231,  233. 
Pryor's  blunt  bullet  forceps,  134. 
forceps,  235. 
intra-uterine    traction    forceps, 

231. 
operating  table,  236. 
packing  applicator,  135. 
retracting  grooved  director,  194. 
trowel,  233. 
uterine  dilator,  135. 
Puerperal  endometritis,  septic,  35. 
See  Endometritis,  puer- 
peral. 
infection,  34. 

state,  vagino-abdominal  liyster- 
ectomy  in,  215. 
Pulse  in  pelvic  peritonitis,  99. 
Purulent  endometritis,  18. 
Pyosalpinx,  80. 
diagnosis,  87. 
sequelcC,  88. 
symptoms,  83. 
treatment,  88. 


Quinin  solution,  237. 


Repeated  irrigations  after  curet- 
tage of  uterus,  133. 
Retractors,  231. 

Pean's,  227. 
Retroposition,  adherent,  117. 

operation  for,  118. 
Rubber    goods,    sterilization    of, 
239- 

S 

Salpingitis,  63. 
gonorrhea],  acute,  63. 
diagnosis,  67. 
sequelae,  68. 
symptoms,  65. 
treatment,  67. 
septic,  acute,  69. 

treatment,  71. 
tubercular,  89. 
symptoms,  90. 
treatment,  90. 
Salpingo-oophoritis,    acute,    con- 
servative   operation   for, 

155- 
Salpingostomy,  158. 
Sclerosis,  genital,  26,  74. 
treatment  of,  74. 
ovarian,  107. 

treatment,  in. 
tubal,  63. 
Secondary  hemorrhage  after  vag- 
inal ablation,  227. 
Section,   vaginal,   preparation    of 

patient  for,  161. 
Speculum,  Jackson,  134. 
Segond's  incisions,  179. 
Septic  endocervicitis,  20. 
diagnosis,  22. 
symptoms,  20. 
treatment,  24. 


INDEX. 


247 


Septic  endometritis,  26.    See  E11- 
doinetritis. 
puerperal  endometritis,  35. 

treatment,  41. 
salpingitis,  acute,  69.     See  also 
Salpingitis. 
chronic,  72.    See  also  Salpin- 
gitis. 
Sheets,  sterilization  of,  240. 
Silks,  sterilization  of,  240. 
Silkworm    gut,     sterilization    of, 

240. 
Silver  wire,  sterilization  of,  240. 
Sims'  artery  forceps,  -235. 
curettes,  135. 
needle-holder,  236. 
tampon  screw,  135. 
Staphylococci,  as  a  cause  of  pelvic 

peritonitis,  92. 
Sterilization,  238. 
Streptococci  as  a  cause  of  pelvic 

peritonitis,  94. 
Subcutaneous  injection  of  normal 

salt  solution,  230. 
Suppuration,  dififuse  pelvic,  123. 
symptoms,  124. 
treatment,  124. 
Suppurative     pelvic     peritonitis, 

treatment,  103. 
Sutures  in  hysterectomy,  166. 
sterilization  of,  240. 

T 

Tampon  screw,  Sims',  135. 
Temperature  in  pelvic  peritonitis, 

100. 
Thiersch  solution,  237. 
Towels,  sterilization  of,  240. 
Traction  instruments,  231. 
Transfusion  fluid,  sterilization  of, 

239- 


Trauma  as  a  cause  of  pelvic  peri- 
tonitis, 96. 
Treatment,  conservative,  146.  See 

Conservative  Ireatinenl. 
Tubal  sclerosis,  63. 
Tubercular  endometritis,  52.    See 
Endometritis. 
pelvic  peritonitis,  104. 
symptoms,  105. 
treatment,  105. 
salpingitis,  89. 
Tympanites  in  pelvic  peritonitis, 
99- 

U 

Ureter,  wounds  of,  in  vaginal  ab- 
lation, 224. 
Ureteritis,  diagnosis  of  pelvic  in- 
flammation from,  58. 
Uterine  colic  in  gonorrheal  endo- 
metritis, 48. 
dilator,  Pryor's,  135. 
Uterus,  ablation  of,  en  masse,  180. 
by  hemisection,  187. 
curettage  of,  126. 
morcellation  of,  209. 
packing  of,  after  curetting,  129. 
vaginal  ablation  of,   163.     See 
also   Vaginal  ablation  of 
icterus,  163. 


Vaginal  ablation  of  uterus,  163. 

accidents    and     complica- 
tions, 223. 
accidents  in,  166. 
after-treatment,  219. 
convalescence  from,  167. 
drainage  in,  165. 
enucleation  in,  165. 
general  considerations,  163. 


248 


INDEX. 


Vaginal  ablation  of  uterus,  hemos- 

tasis  in,  165. 
hernia  after,  166. 
instruments  for,  166. 
operation,  168. 
posture  for,  168. 
results  of,  167. 
secondary     ii  e  m  o  r  r  h  a  g  e 

after,  227. 
separation  of  adhesions  in. 


Vaginal  ablation  of  uterus,  hyste- 
rectomy, 163.    See  Fi/^z- 
7tal  ablation. 
sutures  in,  166. 
section,  exploratory,  136. 
preparation  of  patient  for,  161. 
Vagino-abdominal    hysterectomy 
in  puerperal  state,  215. 

Wales  bougie,  236. 
Womb  cramps,  27. 


Medical  and  Surgical  Works 


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Plan.  until  full  amount  is  paid.  Any  of  the  publications  of  W.  B.  Saunders 

(100  titles  to  select  from)  may  be  had  in  this  way  at  catalogue  price, 
including  the  American  Text-Book  Series,  the  Medical  Hand- 
Atlases,  etc.  All  payments  to  be  made  by  mail  or  otherwise,  free 
of  all  expense  to  us. 


SAUNDERS' 
MEDICAL   HAND-ATLASES. 


The  series  of  books  included  under  this  title  consists  of  authorized  translations 
into  English  of  the  world-famous  Lehmann  Medicinische  Handatlanten, 
which  for  scientific  accuracy,  pictorial  beauty,  compactness,  and  cheap- 
ness surpass  any  similar  volumes  ever  published.  Each  volume  contains  from 
50  to  100  colored  plates,  executed  by  the  most  skilful  German  lithographers, 
besides  numerous  illustrations  in  the  text.  There  is  a  full  and  appropriate  de- 
scription, and  each  book  contains  a  condensed  but  adequate  outline  of  the 
subject  to  which  it  is  devoted. 

In  planning  this  series  arrangements  were  made  with  representative  pub- 
lishers in  the  chief  medical  centers  of  the  world  for  the  publication  of  transla- 
tions of  the  atlases  into  nine  different  languages,  the  lithographic  plates  for  all 
being  made  in  Germany,  where  work  of  this  kind  has  been  brought  to  the  greatest 
perfection.  The  enormous  expense  of  making  the  plates  bemg  shared  by  the 
various  publishers,  the  cost  to  each  one  was  reduced  to  practically  one-tenth. 
Thus  by  reason  of  their  universal  translation  and  reproduction,  affording  in- 
ternational distribution,  the  publishers  have  been  enabled  to  secure  for  these 
atlases  the  best  artistic  and  professional  talent,  to  produce  them  in  the  most 
elegant  style,  and  yet  to  offer  them  at  a  price  heretofore  unapproached 
in  cheapness.  The  great  success  of  the  undertaking  is  demonstrated  by  the 
fact  that  the  volumes  have  already  appeared  in  thirteen  different  languages 
— German,  English,  French,  Italian,  Russian,  Spanish,  Japanese,  Dutch,  Danish, 
Swedish,  Roumanian,  Bohemian,  and  Hungarian. 

In  view  of  the  unprecedented  success  of  these  works,  Mr.  Saunders  has  con- 
tracted with  the  publisher  of  the  original  German  edition  for  one  hundred 
thousand  copies  of  the  atlases.  In  consideration  of  this  enormous  under- 
taking, the  publisher  has  been  enabled  to  prepare  and  furnish  special  additional 
colored  plates,  making  the  series  even  handsomer  and  more  complete  than 
was  originally  intended. 

As  an  indication  of  the  great  practical  value  of  the  atlases  and  of  the  im- 
mense favor  with  which  they  have  been  received,  it  should  be  noted  that  the 
Medical  Department  of  the  U.  S.  Army  has  adopted  the  "Atlas  of  Opera- 
tive Surgery,"  as  its  standard,  and  has  ordered  the  book  in  large  quantities  for 
distribution  to  the  various  regiments  and  army  posts. 

The  same  careful  and  competent  editorial  supervision  has  been  secured  in 
the  English  edition  as  in  the  originals.  The  translations  have  been  edited  by 
the  leading  American  specialists  in  the  different  subjects. 

{^For  List  of  Volumes  in  this  Series,  see  next  two  pages. ) 
3 


SAUNDERS^  MEDICAL  HAND-ATLASES, 

VOLUMES  NOW  READY. 

Atl^  and  Epitome  of  Internal  Medicine  and  Clinical  Diagnosis. 

By  Dr.  Chk.  Jakob,  uf  Erlangcn.  Edited  by  Aui;us  rus  A.  Esunek,  M.  D., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.  With  68  colored 
plates,  64  text-illustrations,  and  259  pages  of  text.     Cloth,  $3.00  net. 

"  The  charm  of  the  book  is  its  clearness,  conciseness,  and  the  accuracy  and  beauty  of  its 
illustrations.  It  deals  with  facts.  It  vividly  diustrates  those  facts.  It  is  a  scientific  work 
put  together  for  ready   reference." — Brooklyn  Mcdkiil  Journiil. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  R.  von  Hokmann,  of  Vienna.  Edited 
by  Fredkrick  rETEKsoN,  M.  D.,  Chief  of  Clinic,  Nervous  Dept.,  College 
of  Physicians  and  Singeons,  New  York.  With  120  colored  figures  on  56 
plates,  and  193  beautiful  half-tone  illustrations.     Cloth,  $3.50  net. 

"  Hofmann's  'Atlas  of  Legal  Metiicine'  is  a  unique  work.  This  immense  field  finds  in  this 
book  a  pictorial  presentation  that  far  e.xcels  anything  with  which  we  are  familiar  in  any  other 
work. " — Fit  ila  delf-lt  ia  Mtdica  I J  on  rria  I. 

Atlas  and  Epitome  of  Diseases  of  the  Larynx.   By  Dr.  L.  Grunwald, 

of  Munich.  Edited  by  Charles  P.  Grayson,  M.  D.,  Phy.sician-in-Charge, 
Throat  and  Nose  Department,  Hospital  of  the  University  of  Pennsylvania. 
With  107  colored  figures  on  44  plates,  25  text-illustrations,  and  103  pages 
of  text.     Cloth,  $2.50  net. 

"Aided  as  it  is  by  magnificently  executed  illustrations  in  color,  it  cannot  fail  of  being  of 
the  greatest  advantage  to  students,  general  practitioners,  and  expert  laryngologists." — St. 
Louis  jilfdiciil  iDui  Su ri^ical  Jon rna/ . 

Atlas  and  Epitome  of  Operative  Surgery.  By  Dr.  O.  Zuckerkandl, 
of  Vienna.  Edited  by  J.  Chalmers  DaCosta,  M.  D.,  Professor  of  Prac- 
tice of  Surgery  and  Clinical  Surgery,  Jefferson  Medical  College,  Philadel- 
phia. With  24  colored  plates,  217  text-illustrations,  and  395  pages  of  text. 
Cloth,  S3.00  net. 

"  We  know  of  no  other  work  vhat  combines  such  a  wealth  of  beautiful  illustrations  with 
clearness  and  conciseness  of  language,  that  is  so  entirely  abreast  of  the  latest  achievements, 
and  so  useful  both  for  the  beginner  and  for  one  who  wishes  to  increase  his  knowledge  of  oper- 
ative surgery." — Munchcncr  mcdicinische  Woclicnschrift. 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Diseases.    By 

Proe.  Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton  Bangs, 
M.  D.,  Professor  of  Genito-Urinary  Surgery,  University  and  Bellevue  Hos- 
pital Medical  College,  New  York.  With  71  colored  plates,  16  black-and- 
white  illustrations,  and  122  pages  of  text.     Cloth,  $3.50  net. 

"A  glance  through  the  book  is  almost  like  actual  attendance  upon  a  famous  clinic." — 
Jourmil  0/  the  American  Medical  Association. 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye.    By  Dr.  O 

Haab,  of  Zurich.  Edited  by  G.  E.  DE  ScHWEiNrrz,  M.  D.,  Professor  of 
Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With  76  colored 
illustrations  on  40  plates,  and  228  pages  of  text.     Cloth,  $3.00  net. 

"  It  is  always  difficult  to  represent  pathological  appearances  in  colored  plates,  but  this 
work  seems  to  have  overcome  these  difficulties,  and  the  plates,  with  one  or  two  exceptions, 
are  absolutely  satisfactory." — Boston  jMedical  and  Surgical  Journal. 

Atlas  and  Epitome  of  Skin  Diseases.     By  Prof.  Dr.  Franz  Mracek, 
of  Vienna.     Edited  by  Henry  W.  Stelwagon,  M.  D.,  Clinical  Professor 
of  Dermatology,  Jefferson  Medical  College,  Philadelphia.    With  63  colored 
plates,  39  halftone  illustrations,  and  200  pages  of  text.    Cloth,  ^3.50  net. 
"The   importance  of  personal  inspection   of  cases   in  the  study  of  cutaneous  diseases  is 
readily  appreciated,  and  next  to  the  living  subjects  are  pictures  which  will  show  the  appear- 
ance of  the  disease  under  consideration.     Altogether   the  work  will  be  found  of  very  great 
value  to  the  general  •pra.cxXuonsr."— Journal 0/  the  Atnerican  Medical  Association. 

4 


SAUNDERS^  MEDICAL  HAND-ATLASES. 


VOLUMES  IN  PRESS  FOR  EARLY  PUBLICATION. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.     By  Dk.  Ed. 

GoLEBiEWSKi,  of  Berlin.  Translated  and  edited  with  additions  by  Pearce 
Bailey,  M.D.,  Attending  Physician  to  the  Department  of  Corrections 
and  to  the  Almshouse  and  Incurable  Hospitals,  New  York.  With  40 
colored  plates,  143  text-illustrations,  and  600  pages  of  text. 
Atlas  and  Epitome  of  Special  Pathological  Histology.  By  Dr.  H. 
DuRCK,  of  Munich.  Edited  by  LuDViG  Hektoen,  M.D.,  Professor  of 
Pathology,  Rush  Medical  College,  Chicago.  Two  volumes,  with  about 
120  colored  plates,  numerous  text-illustrations,  and  copious  text. 

Atlas  and  Epitome  of  General  Pathological  Histology.  With  an 
Appendix  on  Patho-histological  Technic.  By  Dr.  H.  Durck,  of  Munich. 
Edited  byLuDViG  Hektoen,  M.D.,  Professor  of  Pathology,  Rush  Medi- 
cal College,  Chicago.  With  80  colored  plates,  numerous  text-illustrations, 
and  copious  text. 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of  the 
University  of  Heidelberg.  With  90  colored  plates,  65  text- illustrations, 
and  308  pages  of  text.  Edited  by  Richard  C.  Norris,  A.  M.,  M.  D., 
Gynecologist  to  the  Philadelphia  and  the  Methodist  Episcopal  Hospitals. 

IN  PREPARATION. 

Atlas  and  Epitome  of  Orthopedic  Surgery.     By  Dr.  Schultess  and 

Dr.  Tuning,  of  Zurich.     About  100  colored  illustrations. 
Atlas  and  Epitome  of  Operative  Gynecology.    By  Dr.  O.  Schaffer, 

of  Heidelberg.      With  40  colored  plates  and  numerous    illustrations   in 

black  and  white  from  original  paintings. 
Atlas  and  Epitome  of  Diseases  of  the  Ear.     Edited  by  Prof.  Dr. 

POLITZER,  of  Vienna,  and  Dr.  G.  Bruhl,  of  Berlin.     With  120  colored 

illustrations  and  about  200  pages  of  text. 
Atlas  and  Epitome  of  General  Surgery.     Edited  by  Dr.  Marwedel, 

with  the  cooperation  of  Prof.   Dr.  Czerny.     With  about  200  colored 

illustrations. 
Atlas  and  Epitome  of  Psychiatry.   By  Dr.  Wilh.  Weygandt,  of  Wiirz- 

burg.     With  about  120  colored  illustrations. 
Atlas  and  Epitome  of  Normal  Histology.   By  Dr.  Johannes  Sobotta, 

of  Wiirzburg.      With  80  colored  plates  and  numerous  illustrations. 
Atlas  and  Epitome  of  Topographical   Anatomy.      By  Prof.   Dr. 

Schultze,  of  Wiirzburg.     About   100  colored   illustrations  and   a   very 

copious  text. 

5 


IV.   B.   SAUNDERS' 


*THE  INTERNATIONAL  TEXT-BOOK  OF  SURGERY.  In 
two  volumes.  By  American  and  British  authors.  Edited  by  J.  Col- 
lins Warren,  M.D.,  LL.D.,  Professor  of  Surgery,  Harvard  Medical  School, 
Boston ;  Surgeon  to  the  Massachusetts  General  Hospital ;  and  A.  Pearck 
Gould,  M.  S.,  F.  R.  C.  S.,  Eng.,  Lecturer  on  Practical  Surgery  and  Teacher 
of  Operative  Surgery,  Middlesex  Hospital  Medical  School;  Surgeon  to  the 
Middlesex  Hospital, London,  England.  Vol.  I. — General  and  Operative 
Surgery. — Handsome  octavo  volume  of  947  pages,  with  458  beautiful 
illustrations,  and  9  lithographic  plates.  Vol.  II. — Special  or  Regional 
Surgery. — Handsome  octavo  volume  of  1050  pages,  with  over  500  wood- 
cuts and  half-tones,  and  8  lithographic  plates.  Prices  per  volume  :  Cloth, 
$5.00  net ;  Half-Morocco,  ^6.00  net. 

Just  Issued. 

In  presenting  a  new  work  on  surgery  to  the  medical  profession  the  publisher 
feels  that  he  need  offer  no  apology  for  making  an  addition  to  the  list  of  excellent 
works  already  in  existence.  Modern  surgery  is  still  in  the  transition  stage  of  its 
development.  The  art  and  science  of  surgery  are  advancing  rapidly,  and  the 
number  of  workers  is  now  so  great  and  so  widely  spread  through  the  whole  of 
the  civilized  world  that  there  is  certainly  room  for  another  work  of  reference 
which  shall  be  untrammelled  by  many  of  the  traditions  of  the  past,  and  shall  at 
the  same  time  present  with  due  discrimination  the  results  of  modern  progress. 
There  is  a  real  need  among  practitioners  and  advanced  students  for  a  work  on 
surgery  encyclopedic  in  scope,  yet  so  condensed  in  style  and  arrangement  that 
,  the  matter  usually  diffused  through  four  or  five  volumes  shall  be  given  in  one- 
half  the  space  and  at  a  correspondingly  moderate  cost. 

The  ever-widening-field  of  surgery  has  been  developed  largely  by  special 
work,  and  this  method  of  progress  has  made  it  practically  impossible  for  one 
man  to  write  authoritatively  on  the  vast  range  of  sulijects  embraced  in  a  modern 
text-book  of  surgery.  In  order,  therefore,  to  accomplish  their  object,  the  editors 
have  sought  the  aid  of  men  of  wide  experience  and  established  reputation  in  the 
various  departments  of  surgery. 


Dr.  Robert  W.  Abbe. 
C.  H.GoldingBird. 
E.  H.  Bradford. 
\V.  T.  Bull. 
T.  G.  A.  Burns. 
Herbert  L.  Burrell. 
R.  C.  Cabot. 
I.  H.  Cameron. 
James  Cantlie. 
W.  Watson  Cheyne. 
William  B.  Clarke. 
William  B.  Coley.  ' 
Edw.  Treacher  Collins. 
H.  Holbrook  Curti.s. 
J.  Chalmers  Da  Costa. 
N.  P.  Dandridge. 
John  B.  Deaver. 
J.  W.  Elliot. 
Harold  Ernst. 


€ONTRIBlTTORS : 

Dr.  Christian  Fenger. 
W.  H.  Forwood. 
George  R.  Fowler. 
George  W.  Gay. 
A.  Pearce  Gould. 
J.  Orne  Green. 
John  B.  Hamilton. 
M.  L.  Harris. 
Fernand  Henrotin. 
G.  H.  Makins. 
Rudolph  Matas. 
Charles  McBurney. 
A.  J.  McCosh. 
L.  S.  McMurtry. 
J.  Ewing  Mears. 
George  H.  Monks. 
John  Murray. 
Robert  W.  Parker. 


Dr.  Rushton  Parker. 
George  A.  Peters. 
Franz  Pfaff. 
Lewis  S.  Pilcher. 
James  J.  Putnam. 
M.  H.  Richardson. 
A.  W.  Mayo  Robson. 
W.  L.  Rodman. 
C.  A.  Siegfried. 
G.  B.  Smith. 
W.  G.   Spencer. 
J.  Bland  Sutton. 
L.  McLane  Tiffany. 
H.  Tuholske. 
Weller  Van  Hook. 
James  P.  Warbasse. 
J.  Collins  Warren. 
De  Forest  Willard. 


CATALOGUE    OF  MEDICAL    WORKS. 


*AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  Edited  by 
William  H.  Howell,  Ph.  D.,  M.  D.,  Professor  of  Physiology  in  the 
Johns  Hopkins  University,  Baltimore,  Md.  One  handsome  octavo  volume 
of  1052  pages,  fully  illustrated.  Prices:  Cloth,  ^6.00  net;  Sheep  or  Half- 
Morocco,  jJSy.oo  net. 

This  work  is  the  most  notable  attempt  yet  made  in  America  to  combine  ii7 
one  volume  the  entire  subject  of  Human  Physiology  by  well-known  teachers 
who  have  given  especial  study  to  that  part  of  the  subject  upon  which  they  write. 
The  completed  work  represents  the  present  status  of  the  science  of  Physiology, 
particularly  from  the  standpoint  of  the  student  of  medicine  and  of  the  medical 
practitioner. 

The  collaboration  of  several  teachers  in  the  preparation  of  an  elementary  text- 
book of  physiology  is  unusual,  the  almost  invariable  rule  heretofore  having  been 
for  a  single  author  to  write  the  entire  book.  One  of  the  advantages  to  be  derived 
from  this  collaboration  method  is  that  the  more  limited  literature  necessary  for 
consultation  by  each  author  has  enabled  him  to  base  his  elementary  account 
upon  a  comprehensive  knowledge  of  the  subject  assigned  to  him ;  another,  and 
perhaps  the  most  important,  advantage  is  that  the  student  gains  the  point  of  view 
of  a  number  of  teachers.  In  a  measure  he  reaps  the  same  benefit  as  would  be 
obtained  by  following  courses  of  instruction  under  different  teachers.  The 
different  standpoints  assumed,  and  the  differences  in  emphasis  laid  upon  the 
various  lines  of  procedure,  chemical,  physical,  and  anatomical,  should  give  the 
student  a  better  insight  into  the  methods  of  the  science  as  it  exists  to-day.  The 
work  will  also  be  found  useful  to  many  medical  practitioners  who  may  wish  to 
keep  in  touch  with  the  development  of  modern  physiology. 

COHTTRIBrXORS : 


HENRY  P.  BOWDITCH,  M.  D., 

Professor  of  Physiology,  Harvard  Medi- 
cal School. 

JOHN  G.  CURTIS,  M.  D., 

Professor  of  Physiology,  Columbia  Uni- 
versity, N.  Y.  (College  of  Physicians 
and  Surgeons). 

HENRY  H.  DONALDSON,  Ph.  D., 

Head-Professor  of  Neurology,  Univer- 
sity of  Chicago. 

W.  H.  HOWELL,  Ph.  D.,  M.  D., 

Professor  of  Physiology,  Johns  Hopkins 
Universitj'. 

FREDERIC  S.  LEE,  Ph.  D., 

Adjunct  Professor  of  Physiology,  Colum- 
bia University,  N.  Y.  (College  of 
Physicians  and  Surgeons). 


WARREN  P.  LOMBARD,  M.  D., 

Professor   of  Physiology,  University  of 
Michigan. 

GRAHAM  LUSK,  Ph.D., 

Professor  of  Physiology,   Yale   Medicaf 
School. 

W.  T.  PORTER,  M.D., 

Assistant  Professor  of  Physiology,  Hat" 
yard  Medical  School. 

EDWARD  T.  REICHERT,  M.D., 

Professor  of  Physiology,  University   of 
Pennsylvania. 

HENRY  SEWALL,  Ph.D.,  M.D., 

Professor  of  Physiology,  Medical  Depart 
ment.  University  of  Denver. 


"  We  can  commend  it  most  heartily,  not  only  to  all  students  of  physiology,  but  to  every 
physician  and  pathologist,  as  a  valuable  and  comprehensive  work  of  reference,  written  by 
men  who  are  of  eminent  authority  in  their  own  special  subjects."  — Z£7?zrfo«  Laiicet. 

"  To  the  practitioner  of  medicine  and  to  the  advanced  student  this  volume  constitutes, 
we  believe,  the  best  exposition  of  the  present  stilus  of  the  science  of  physiology  in  the  Eng- 
lish language." — American  yournal  of  the  Medical  Sciences. 


8 


PV.    B.    SAUNDERS' 


*AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEU- 
.  TICS.  For  the  Use  of  Practitioners  and  Students.  Edited  by 
James  C.  Wilson,  M.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine  in  the  Jefferson  Medical  College.  One  handsome  octavo 
volume  of  1326  pages.  Illustrated.  Prices:  Cloth,  $7.00  net;  Sheep  or 
Half-Morocco,  ^8.00  net. 

The  arrangement  of  this  volume  has  been  based,  so  far  as  possible,  upon 
modern  pathologic  doctrines,  beginning  with  the  intoxications,  and  following 
with  infections,  diseases  due  to  internal  parasites,  diseases  of  undetermined 
origin,  and  finally  the  disorders  of  the  several  bodily  systems — digestive,  re- 
spiratory, circulatory,  renal,  nervous,  and  cutaneous.  It  was  thought  proper  to 
include  also  a  consideration  of  the  disorders  of  pregnancy. 

The  articles,  with  two  exceptions,  are  the  contributions  of  American  writers. 
Written  from  the  standpoint  of  the  practitioner,  the  aim  of  the  work  is  to  facili- 
tate the  application  of  knowledge  to  the  prevention,  the  cure,  and  the  allevia- 
tion of  disease.  The  endeavor  throughout  has  been  to  conform  to  the  title  of 
the  book — Applied  Therapeutics — to  indicate  the  course  of  treatment  to  be 
pursued  at  the  bedside,  rather  than  to  name  a  list  of  drugs  that  have  been  used 
at  one  time  or  another. 

The  list  of  contributors  comprises  the  names  of  many  who  have  acquired  dis- 
tinction as  practitioners  and  teachers  of  practice,  of  clinical  medicine,  and  of 
the  specialties. 

CONTRIBVTORiS : 


Dr.  I.  E.  Atkinson,  Baltimore,  Md. 
Sanger  Brown,  Chicago,  111. 
John  B.  Chapin,  Philadelphia,  Pa. 
William  C.  Dabney,  Charlottesville,  Va. 
John  Chalmers  DaCosta,  Philada.,  Pa. 
I.  N.  Danforth,  Chicago,  111. 
John  L.  Dawson,  Jr.,  Charleston,  S.  C. 
F.  X.  Dercum,  Philadelphia,  Pa. 
George  Dock,  Ann  Arbor,  Mich. 
Robert  T.  Edes,  Jamaica  Plain.  Mass. 
Augustus  A.  Eshner,  Philadelphia,  Pa. 
J.  T.  Eskridge,  Denver,  Ccl. 
P.  Forchheimer,  Cincinnati,  O. 
Carl  Frese,  Philadelphia,  Pa. 
Edwin  E.  Graham,  Philadelphia,  Pa. 
John  Guiteras,  Philadelphia.  Pa. 
Frederick  P.  Henry,  Philadelphia,  Pa. 
Guy  Hinsdale,  Philadelphia,  Pa. 
Orville  Horwitz,  Phil.ndelphia,  Pa. 
W.  W.  Johnston,  Washington,  D.  C. 
Ernest  Laplace,  Philadelphia,  Pa. 
A.  Laveran,  Pans,  France. 

"As  a  work  either  for  study  or  reference  it  will  be  of  great  value  to  the  practitioner,  as 
it  is  virtually  an  exposition  of  such  clinical  therapeutics  as  experience  has  taught  to  be  of 
the  most  value.  Taking  it  all  in  all,  no  recent  publication  on  therapeutics  can  be  compared 
with  this  one  in  practical  value  to  the  working  physician." — Chicago  Clinical  Review. 

"  The  whole  field  of  medicine  h.as  been  well  covered.  The  work  is  thoroughly  practical, 
and  while  it  is  intended  for  practitioners  and  students,  it  is  a  better  book  for  the  general 
practitioner  than  for  the  student.  The  young  practitioner  especially  will  find  it  extremely 
suggestive  and  helpful  " — 7'/ie  Indian  Lancet. 


Dr.  James  Hendrie  Lloyd,  Philadelphia,  Pa. 
John  Noland  Mackenzie,  Baltimore,  Md. 
J.  W.  McLaughlin,  Austin,  Texas. 
A.  Lawrence  Mason,  Boston,  Mass. 
Charles  K.  Mills,  Philadelphia,  Pa. 
John  K.  Mitchell,  Philadelphia,  Pa. 
W.  P.  Northrup,  New  York  City. 
William  Osier,  Baltimore,  Md. 
Frederick  A.  Packard,  Philadelphia,  Pa. 
Theophilus  Parvin,  Pbiladelphia,  Pa. 
Beaven  Rake,  London,  England. 
E.  O.  Shakespeare.  Philadelphia.  Pa. 
Wharton  Sinkler,  Philadelphia,  Pa. 
Louis  Starr,  Philadelphia,  Pa. 
Henry  W.  Stelwagon,  Philadelphia,  Pa. 
James  Stewart,  Montreal,  Canada. 
Charles  G.  Stockton,  Euffalo,  N.  Y. 
James  Tyson,  Philadelphia,  Pa. 
Victor  C.  Vaughan,  Ann  Arbor,  Mich. 
James  T.  Whittaker,  Cincinnati,  O. 
J.  C.  Wilson,  Philadelphia,  Pa. 


CATALOGUE    OF  MEDICAL    WORKS. 


*AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS.  Edited  by 
Richard  C.  Norris,  M.  D.  ;  Art  Editor,  Robert  L.  Dickinson,  M.  D. 
One  handsome  octavo  volume  of  over  looo  pages,  with  nearly  900  coloied 
and  half-tone  illustrations.  Prices:  Cloth,  ^7.00  net;  Sheep  or  Half 
Morocco,  ;g8.oo  net. 

The  advent  of  each  successive  volume  of  the  series  of  the  American  Text- 
Books  has  been  signalized  by  the  most  flattering  comment  from  both  the  Press 
and  the  Profession.  The  high  consideration  received  by  these  text-books,  and 
their  attainment  to  an  authoritative  position  in  current  medical  literature,  have 
been  matters  of  deep  international  interest,  which  finds  its  fullest  expression  in 
the  demand  for  these  publications  from  all  parts  of  the  civilized  world. 

In  the  preparadon  of  the  "American  Text-Book  of  Obstetrics"  the 
editor  has  called  to  his  aid  proficient  collaborators  whose  professional  prominence 
entitles  them  to  recognition,  and  whose  disquisitions  exemplify  Practical 
Obstetrics.  While  these  writers  were  each  assigned  special  themes  for  dis- 
cussion, the  correladon  of  the  subject-matter  is,  nevertheless,  such  as  ensures 
logical  connection  in  treatment,  the  deductions  of  which  thoroughly  represent 
the  latest  advances  in  the  science,  and  which  elucidate  the  best  ??iodern  methods 
of  procedure. 

The  more  conspicuous  feature  of  the  treatise  is  its  wealth  of  illustrative 
matter.  The  production  of  the  illustrations  had  been  in  progress  for  several 
years,  under  the  personal  supervision  of  Robert  L.  Dickinson,  M.  D.,  to  whose 
artistic  judgment  and  professional  experience  is  due  the  most  sumptuously 
illustrated  work  of  the  period.  By  means  of  the  photographic  art,  combined 
with  the  skill  of  the  artist  and  draughtsman,  conventional  illustration  is  super- 
seded by  rational  methods  of  delineation. 

Furthermore,  the  volume  is  a  revelation  as  to  the  possibilities  that  may  be 
reached  in  mechanical  execution,  through  the  unsparing  hand  of  its  publisher. 


CO]VTRIBUTORS ; 


Dr.  James  C.  Cameron. 
Edward  P.  Davis. 
Robert  L.  Dickinson. 
Charles  Warrington  Earle. 
James  H.  Etheridge. 
Henry  J.  Garrigues. 
Barton  Cooke  Hirst. 
Charles  Jewett. 


Dr.  Howard  A.  Kelly. 
Richard  C.  Norris. 
Chauncey  D.  Palmer. 
Theophilus  Parvin. 
George  A.  Piersol. 
Edward  Reynolds. 
Henry  Schwarz. 


"At  first  glance  we  are  overwhelmed  by  the  magnitude  of  this  work  in  several  respects, 
viz.  :  First,  by  the  size  of  the  volume,  then  by  the  array  of  eminent  teachers  in  this  depart- 
ment who  have  taken  part  in  its  production,  then  by  the  profuseness  and  character  of  the 
illustrations,  and  last,  but  not  least,  the  conciseness  and  clearness  with  which  the  text  is  ren- 
dered. This  is  an  entirely  new  composition,  embodying  the  highest  knowledge  of  the  art  as 
it  stands  to-day  by  authors  who  occupy  the  front  rank  in  their  specialty,  and  there  are  many 
of  them.  We  cannot  turn  over  these  pages  without  being  struck  by  the  superb  illustrations 
which  adorn  so  many  of  them.  We  are  confideiit  that  this  most  practical  work  will  find 
instant  appreciation  by  practitioners  as  well  as  students." — Netu  York  Medical  Times. 

Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  1  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers. 

With  profound  respect  I  am  sincerely  yours,  Alex.  J.  C.  Skene. 


lO  ff^.   B.   SAUNDERS' 


*  AN  AMERICAN  TEXT-BOOK  OF  THE  THEORY  AND 
.  PRACTICE  OF  MEDICINE.  By  American  Teachers.  Edited 
by  \Vil,Ll.\M  I'KrPKU,  M.  1)..  l.I,  I).,  Provost  and  Professor  of  the  Theory 
and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University  of 
Pennsylvania.  Complete  in  two  handsome  royal -octavo  voliunes  of  about 
lOOO  pages  each,  with  illustrations  to  ehu  itlate  the  text  wherever  necessary. 
Price  per  \olume  :   Cloth,  SS-OO  nit  ;  Sheep  or  Half-Morocco,  ;g6.00  net. 

VOL.IJIWE   I.  COXrAIJ^I*: 

Hygiene.— Fevers (tphemeral,  bimple  Con-  myc^si^,  'jl.mders,  and  Tetanus. —  I'ubercu- 
nnuect.  Typhus,  Typhoid,  Epidemic  Cerebro-  ,  lo^^is,  Scroiula,  Syphilis,  Diphtheria,  Erysipe- 
jpinal  Meningitis,  and  Relapsing)  — Sc;irla-  I  Ia3,  frialaria.  Cholera,  and  Vellow  Fever. — 
:ina.  Measles,  Rotheln,  Varii^la,  Varioloid,  1  Nervous,  Muscular,  and  iMental  Diseases  etc. 
Vjccinia. Varicella,  Mumps, Whooping  cciish.  i 
Anthrax.  Hydrophobia,  Trichinosis.  Acr.ino.  i 

■Jrine  (Chemistry  and  MicrosLipy)  —Kid-  [  — Herirrneuiii,  Livci  and  f?.ncreas.  —  Uiathet- 
r.ey  and  Lungs. — Air-passages  (Laryii.ic  and  [  ic  Diseases  (Kheum.itism,  Khcumatoid  Ar- 
Bronchi)  and  Pleura. —  Pharynx,  (E'ioph.igns.  I  tliritis.  Gout,  Liiha:ini.i,  ami  Diabetes.) — 
Stomach  and  Intestines  (including  Inti^siinal  Blood  and  Spleen.  —  lnflaminati..n.  Embolism, 
Parasites),  Heart,  Aorta,  Arteries  and  Veins.  |  Thrombosis,  Fever,  and  Bacteriology. 

The  articles  are  not  wriiten  as  thouoh  addressed  to  student-  in  lectures,  but 
are  exhaustive  descriptions  of  diseases,  with  the  newest  facts  as  regards  Causa- 
tion, Symptomatology,  Diagnosis,  Prognosis,  and  Treatment,  including  a  large 
number  of  approved  formulae.  The  recent  advances  made  in  llie  study 
of  the  bacterial  origin  of  various  diseases  are  fully  described,  as  well  as  the 
bearing  of  the  knowledge  so  gained  upon  prevention  and  cure.  The  subjects 
of  Bacteriology  as  a  whole  and  of  Immunity  are  fully  considered  in  a  scoaraie 
section. 

Methods  of  diagnosis  are  given  the  most  mmute  and  careful  attention,  thus 
enabling  the  reader  to  learn  the  very  latest  methods  of  investigation  without 
consultine  works  specially  devoted  to  the  suhiect. 

CONTK.IBrTOB!»»  - 

i>r.  I.  S.  Billings,  Philadelphia.  I  D:.  V'illiam  Pepper,  Philadelohla. 

Francis  Delafield,  New  York.  V.  Oilman  Thompson,  New  York 

Reginald  H.  Fitz,  Boston.  i  W.  H.  Welch,  Baliimore 

James  W.  Holland,  Philadelphia.  |  James  T.  Whiitaker.  Cincinnati 

Henry  M.  Lyman,  Chicagc.  James  C.  Wilson.  Philadeipni  i. 

William  Osier.  Baltimore  TJoratio  C.  Wood,  Philadelphia. 

''  We  reviewed  the  first  volume  of  tnis  work,  and  said;  '  It  is  undoubtedly  one  ot  tne  best 
text-books  on  the  practice  ol  medicine  which  we  possess.'  A  consideration  of  the  secon'J 
a.nd  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work  K,  in  out 
opinion,  the  best  of  its  kind  it  has  ever  been  our  toriune  to  see.  It  is  complete,  thorough, 
accurate,  and  clear.  It  is  well  written,  well  arranged,  well  printed,  well  illustrated,  and  well 
Dound.    It  is  a  model  of  what  the  modern  text-book  should  he/'—Ne^v  Vot  k  Medical  Journal. 

'A  library  upon  modern  medical  art.  Tne  work  must  promote  the  wider  diffusion  ef 
sound   knowledge." — American  Lane*. 

"  A  trusty  counsellor  for  the  practitioner  Oi-  senior  student,  on  winch  ne  may  implicitly 
-••IV.'' — Jieiiniurg-h  Medical  'fovrna.1 


CATALOGUE    OF  MEDICAL    WORKS.  II 

*AN  AMERICAN  TEXT-BOOK  OF  SURGERY.  Edited  by  Wil- 
liam W.  Keen,  M.  D.,  LL.D.,  and  J.  William  White,  M.  D.,  Ph.  D. 
Forming  one  handsome  royal  octavo  volume  of  1230  pages  (10  x  7  inches), 
with  496  virood-cuts  in  text,  and  37  colored  and  half-tone  plates,  many  of 
them  engraved  from  original  photographs  and  drawings  furnished  by  the 
authors.     Price  :  Cloth,  $7.00  net;  Sheep  or  Half  Morocco,  ^8.00  net. 

THIRD  EDITION.  THOROUGHLY  REVISED. 

In  the  present  edition,  among  the  new  topics  introduced  are  a  full  considera- 
tion of  serum-theiapy;  leucocytosis  ;  post-operative  insanity;  the  use  of  dry  heat 
at  high  temperatures ;  Kronlein's  method  of  locating  the  cerebral  fissures ; 
Hoffa's  and  I.orenz's  operations  of  congenital  dislocations  of  the  hip  ;  Allis's  re- 
searches on  dislocations  of  the  hip-joint ;  lumbar  puncture  ;  the  forcible  reposi- 
tion of  the  spine  in  Pott's  disease;  the  treatment  of  exophthalmic  goiter;  the 
surgery  of  typhoid  fever ;  gastrectomy  and  other  operations  on  the  stomach ; 
new  methods  of  operating  upon  the  intestines;  the  use  of  Kelly's  rectal  specula; 
the  surgery  of  the  ureter ;  Schleich's  infiltration-method  and  the  use  of  eucain 
for  local  anesthesia ;  Krause's  method  of  skin-grafting  ;  the  newer  methods  of 
disinfecting  the  hands ;  the  use  of  gloves,  etc.  The  sections  on  Appendicitis, 
on  Fractures,  and  on  Gynecological  Operations  have  been  revised  and  enlarged. 
A  considerable  number  of  new  illustrations  have  been  added,  and  enhance  the 
value  of  the  work. 

The  text  of  the  entire  book  has  been  submitted  to  all  the  authors  for  their 
mutual  criticism  and  revision — an  idea  in  book- making  that  is  entirely  new  and 
original.  The  book  as  a  whole,  therefore,  expresses  on  all  the  important  sur- 
gical topics  of  the  day  the  consensus  of  opinion  of  the  eminent  surgeons  who 
have  joined  in  its  preparation. 

One  of  the  most  attractive  features  of  the  book  is  its  illustrations.  Very 
many  of  them  are  original  and  faithful  reproductions  of  photographs  taken 
directly  from  patients  or  from  specimens, 

CONTRIBCTOKS : 


Dr.  Phineas  S.  Conner,  Cincinnati. 
Frederic  S.  Dennis,  New  York. 
William  W.  Keen,  Philadelphia. 
Charle.s  B.  Nancrede,  Ann  Arbor,  Mich. 
Roswell  Park,  Buffalo,  New  York. 
Lewis  S.  Pilcher,  New  York. 


Dr.  Nicholas  Senn,  Chicago. 

Francis  J.  Shepherd,  Montreal,  Canada. 

Lewis  A.  Slimson,  New  York. 

J.  Collins  Warren,  Boston. 

J.  William  White,  Philadelphia. 


"If  this  text-book  is  a  fair  reflex  of  the  present  position  of  A.merican  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 
London  Lancet. 

Personally,  I  should  not  mind  it  being  called  THE  Text-Book  (instead  of  A  Text-Book), 
for  1  know  ot  no  single  volume  which  contains  so  readable  and  complete  an  account  of  the 
science  and  art  of  Surgery  as  this  does." — Edmund  Owen,  F.  R.  C.  S.,  Member  of  the  Board 
nf  Examiners  of  the  Royal  College  of  Surgeons,  Rns:iand 


12  IV.   B.    SAUNDERS' 


*  AN  AMERICAN  TEXT-BOOK  OF  GYNECOLOGY,  MEDICAL 
AND  SURGICAL,  for  the  use  of  Students  and  Practitioners. 
Edited  by  J.  M.  Bai.dy,  M.  D.  Forming  a  handsome  royal-octavo  volume 
of  718  pages,  with  341  illustrations  in  the  text  and  38  colored  and  half- 
tone plates.     Prices  :  Cloth,  $6.00  net ;  Sheep  or  Half-Morocco,  ;^7.oo  net. 

SECOND  EDITION,  THOROUGHLY  REVISED. 

In  this  volume  all  anatomical  descriptions,  excepting  those  essential  to  a  clear 
undeistanding  of  the  text,  have  been  omitted,  the  illustrations  being  largely  de- 
pended upon  to  elucidate  the  anatomy  of  the  parts.  This  work,  which  is 
thoroughly  practical  in  its  teachings,  is  intended,  as  its  title  implies,  to  be  a 
working  text-book  for  physicians  and  students.  A  clear  line  of  treatment  has 
been  laid  down  in  every  case,  and  although  no  attempt  has  been  made  to  dis- 
cuss mooted  points,  still  the  most  important  of  these  have  been  noted  and  ex- 
plained. The  oper.ations  recommended  aie  fully  illustrated,  so  tliat  the  reader, 
having  a  picture  of  the  i)rocedine  described  in  the  text  under  his  eye,  cannot  fail 
to  giasp  the  idea.  All  extraneous  matter  and  discussions  have  been  carefully 
exchuled,  the  attempt  being  made  to  allow  no  unnecessary  details  to  cumber 
the  text.  The  subject-matter  is  brought  up  to  date  at  every  point,  and  the 
work  is  as  nearly  as  possible  the  combined  opinions  of  the  ten  specialists  who 
figure  as  the  authors. 

In  the  revised  edition  much  new  material  has  been  added,  and  some  of  the 
old  eliminated  or  modified.-  More  than  forty  of  the  old  illustrations  have  been 
replaced  by  new  ones,  which  add  very  materially  to  the  elucidation  of  the 
text,  as  they  picture  methods,  not  specimens.  The  chapters  on  technique  and 
after-treatment  have  been  considerably  enlarged,  and  the  portions  devoted  to 
plastic  work  have  been  so  greatly  improred  as  to  be  practically  new.  Hyste- 
rectomy has  been  rewritten,  and  all  the  descriptions  of  operative  procedures 
have  been  carefully  revised   and   fully  illustrated. 


CODTTRIBUTORS : 


Dr.  Henry  T.  Byford. 
John  M.  Baldy. 
Edwin  Cragin. 
1.  H.  Etheridge. 
William  Goodell. 


Dr.  Howard  A.  Kelly. 
Fiorian  Krug. 
E.  E.  Montgomery. 
William  R.  Pryor. 
George  M.  Tuttle. 


"The  most  notable  contribution  to  gynecological  literature  since  1887 and  the  most 

complete  exponent  of  gynecology  which  we  have.  No  subject  seems  to  have  been  neglected, 
....  and  the  gynecologist  and  surgeon,  and  the  general  practitioner  who  has  any  desire 
to  practise  diseases  of  women,  will  find  it  01"  practical  value.  In  the  matter  of  illustrations 
and  plates  the  book  surpasses  anything  we  have  seen." — Boston  Medical  and  Surgical 
yournal. 

"  A  thoroughly  modern  text-book,  and  gives  reliable  and  well-tempered  advice  and  in- 
struction."— Edinburgh  Medical  Journal. 

"  The  harmony  of  its  conclusions  and  the  homogeneity  of  its  style  give  it  an  individuality 
which  suggests  a  single  rather  than  a  multiple  authorship."— ^««a/.r  0/  Surgery. 

"  It  must  command  attention  and  respect  as  a  worthy  representation  of  our  advanced 
clinical  teaching." — American  Journal  of  Medical  Sciences. 


CATALOGUE    OF  MEDICAL    WORKS. 


13 


*AN  AMERICAN  TEXT-BOOK  OF  THE  DISEASES  OF  CHIL- 
DREN. By  American  Teachers.  Edited  by  Louis  Starr,  M.  D., 
assisted  by  Thompson  S.  Westcott,  M.  D.  In  one  handsome  reyal-Svi 
volume  of  1244  pages,  profusely  illustrated  with  wood-cuts,  half-tone  and 
colored  plates.    Net  Prices:  Cloth,  ^7.00;  Sheep  or  Half- Morocco,  p.oo. 

SECOND  EDITION,  REVISED  AND  ENLARGED. 

The  plan  of  this  work  embraces  a  series  of  original  articles  written  by  some 
sixty  well-known  pcediatrists,  representing  collectively  the  teachnigs  of  the  most 
prominent  medical  schools  and  colleges  of  America.  The  work  is  intended  to 
be  a  PRACTICAL  book,  suitable  for  constant  and  handy  reference  by  the  practi- 
tioner and  the  advanced  student. 

Especial  attention  has  been  given  to  the  latest  accepted  teachings  upon  the 
etiology,  symptoms,  pathology,  diagnosis,  and  treatment  of  the  disorders  of  chil- 
dren, with  the  introduction  of  many  special  formulae  and  therapeutic  procedures. 

In  this  new  edition  the  whole  subject  matter  has  been  carefully  revised,  new 
articles  added,  some  original  papers  emended,  and  a  number  entirely  rewritten. 
The  new  articles  include  "  Modified  Milk  and  Percentage  Milk-Mixtures," 
"  Lithemia,"  and  a  section  on  "  Orthopedics."  Those  rewritten  are  "  Typhoid 
Fever,"  "Rubella,"  "Chicken-pox,"  "Tuberculous  Meningitis,"  "Hydroceph- 
alus," and  "Scurvy;"  while  extensive  revision  has  been  made  in  "Infant 
Feeding,"  "  Measles,"  "  Diphtheria,"  and  "  Cretinism."  The  volume  has  thus 
been  much  increased  in  size  by  the  introduction  of  fresh  material. 

CONTRIBUTORS  1 


Dr.  S.  S.  Adams,  Washington. 

John  Ashhurst,  Jr.,  Philadelphia. 
A.  D.  Blackader,  Montreal,  Canada. 
David  Bovaird,  New  York. 
Dillon  Brown,  New  York. 
Edward  M.  Buckingham,  Boston. 
Charles  W.  Burr,  Philadelphia. 
W.  E.  Casselberry,  Chicago. 
Henry  Dwight  Chapin,  New  York. 
W.  S.  Christopher,  Chicago. 
Archibald  Church,  Chicago. 
Floyd  M.  Crandall,  New  York. 
Andrew  F.  Currier,  New  York. 
Roland  G.  Ciirtin,  Philadelphia 
J.  M.  DaCosta,  Philadelphia. 
I.  N.  Danforth,  Chicago. 
Edward  P.  Davis,  Philadelphia. 
John  B.  Deaver,  Philadelphia. 
G.  E.  de  Schweinitz,  Philadelphia. 
John  Doming,  New  York. 
Charles  Warrington  Earle,  Chicago. 
Wm.  A.  Edwards,  San  Diego,  Cal. 
F.  Forchheimer,  Cincinnati. 
J.  Henry  Fruitnight,  New  York. 
J.  P.  Crozer  Griffith,  Philadelphia. 
W.  A.  Hardaway.  St.  Louis. 
M.  P   Hatfield,  Chicago. 
Barton  Cooke  Hirst,  Philadelphia. 
H.  lUoway,  Cincinnati. 
Henry  Jackson,  Boston. 
Charles  G.  Jennings,  Detroit 
Henry  Koplik.  New  York. 


Dr.  Thomas  S.  Latimer,  Baltimore. 

Albert  R.  Leeds,  Hoboken,  N.  J. 

J.  Hendrie  Lloyd,  Philadelphia. 

George  Roe  Lockwood,  New  York. 

Henry  M.  Lyman,  Chicago. 

Francis  T.  Miles,  Baltimore. 

Charles  K    Mills,  Philadelphia. 

James  E.  Moore,. Minneapolis. 

F.  Gordon  Morrill,  Boston. 

John  H.  Musser,  Philadelphia. 

Thomas  R.  Neilson,  Philadelphia. 

W.  P.  Northrup,  New  York. 

William  Osier,  Baltimore. 

Frederick  A.  Packard,  Philadelphia. 

William  Pepper,  Philadelphia. 

Frederick  Peterson,  New  York. 

W.  T.  Plant,  Syracuse,  New  York 

William  M.  Powell.  Atlantic  City. 

B.  K.  Rachford,  Cincinnati. 

B.  Alexander  Randall,  Philadelphia. 

Edward  O.  Shakespeare,  Philadelphia 

F.  C.  Shattuck,  Boston. 

J.  Lewis  Smith,  New  York. 

Louis  Starr,  Philadelphia. 

M.  Allen  Starr,  New  York. 

Charles  W.  Townsend,  Boston. 

James  Tyson,  Philadelphia. 

W.  S.  Thayer,  Baltimore. 

Victor  C.  Vaughan,  Ann  Arbor,  Mich 

Thompson  S.  Westcott,  Philadelphia. 

Henry  R.  Wharton,  Philadelphia. 

J.  William  White,  Philadelphia. 

J.  C.  Wilson,  Philadelphia. 


14 


IV.   B.   SAUNDERS' 


*AN  AMERICAN  TEXT-BOOK  OF  GENITO-URINARY  AND 
SKIN  DISEASES.  Dy  47  Eminent  Specialists  and  Teachers.  Edited 
by  L.  Bolton  Bangs,  M.  D.,  Piofessor  of  Genito-Uriiiary  Surgery,  Uni- 
versity and  Bellevue  Hospital  Medical  College,  New  York ;  and  W.  A. 
Hardaway,  M.  D.,  Professor  of  Diseases  of  the  Skin.  Missouri  Medical 
College.  Imperial  octavo  volume  of  1229  pages,  vi^ith  300  engravings  and 
20  full-page  colored  plates.  Cloth,  $7.00  net ;  Sheep  or  Half  Morocco, 
$8.00  net. 

This  addition  to  the  series  of  "  American  Text-Books,"  it  is  confidently  be- 
lieved, will  meet  the  requirements  of  both  students  and  jiractitioners,  giving,  as 
it  does,  a  comprehensive  and  detailed  presentation  of  the  Diseases  of  the 
Genito-Urinary  Organs,  of  the  Venereal  Diseases,  and  of  the  Affections  of  the 
Skin. 

Having  secured  the  collaboration  of  well-known  authorities  in  the  branches 
represented  in  the  undertaking,  the  editors  have  not  restricted  the  contributors 
iu  regard  to  the  particular  views  set  forth,  but  have  oftered  every  facility  for  the 
free  e.xpressiun  of  their  individual  opinions.  The  work  will  therefore  be  found 
to  be  original,  yet  homogeneous  and  fully  representative  of  the  several  depart- 
ments of  medical  science  with  which  it  is  concernea. 


€OXTRIBlJTORS : 


Dr.  Chas.  W.  Allen,  New  York. 
1.  E.  Atkinson,  Baltimore. 
L   Bolton  Bangs,  New  York. 
P.  R.  Bolton,  New  York. 
Lewis  C.  Bosher,  Richmond,  Va. 
John  T.  Bowen,  Boston. 
J.  Abbott  Cantrell.  Philadelphia. 
William  T.  Corlett,  Cleveland,  Ohio. 
B.  Farquhar  Curtis,  New  York. 
Condict  \V.  Cutler,  New  York. 
Isadore  Dyer,  New  Orleans. 
Christian  Fenger,  Chicago. 
John  A.  Fordyce,  New  York. 
Eugene  Fuller,  New  York. 
R.  H.  Greene,  New  York. 
Joseph  Grindon,  St.  Louis. 
Graeme  M.  Hammond,  New  York. 
\V.  A.  Hardaway,  St.  Louis. 
M.  B.  Hartzell,  Philadelphia. 
Louis  Heitzmann,  New  York. 
James  S.  Howe,  Boston. 
George  T.  Jackson,  New  York. 
Abraham  JacobI,  New  York. 
James  C.  Johnston.  New  York. 


Dr.  Hermann  G.  Klotz,  New  Ybrle. 
J.  H.  Linslcy,  Burlington,  Vt, 
G.  F.  Lydston,  Chicago. 
Hartwell  N.  Lyon,  St.  Louis. 
Edward  Martin,  Philadelphia. 
D.  G.  Montgomery,  San  Francisco. 
James  Pedersen,  New  York. 
S.  Pollitzer,  New  York. 
Thomas  R.  Pooley,  New  York. 
A.  R.  Robinson,  New  York. 
A.  E.  Rtgensburger,  San  Francisco. 
Francis  J.  Shepherd,  Montreal,  Can. 
S.  C.  Stanton,  Chicago,  ill. 
Emmanuel  J.  Stout,  Philadelphia. 
Alonzo  E.  Taylor.  Philadelphia. 
Robert  W.  Taylor,  New  York. 
Paul  Thorndike,  Boston. 
H.  Tuholske,  St.  Louis. 
Arthur  Van  Harlingen,  Philadelphia. 
Francis  S.  Watson,  Boston. 
J.  William  White,  Philadelphia. 
J.  McF.  Winfield,  Brooklyn. 
Alfred  C.  Wood,  Philadelptiia. 


"This  voluminous  work  is  thoro\ighly  up  to  date,  and  the  chapters  on  genito-urinarv  ais- 
eases  are  especially  valuable.  The  illustrations  are  fine  and  are  mostly  original.  The  section 
on  dermatology  is  concise  and  in  every  way  admirable."— VoM^'wa/  of  the  Atnerican  Medical 
Association. 

"This  volume  is  one  of  the  best  yet  issued  of  the  publisher's  series  of  'American  Te.\t- 
Books.'  The  list  of  contributors  represents  an  e.vtraordinary  array  of  talent  and  extended 
experience.  The  book  will  easily  take  the  place  in  comprehensiveness  and  value  of  the 
half  dozen  or  more  costly  works  on  these  subjects  which  have  hitherto  been  necessary  to  a 
well-equipped  library." — New  York  Polvdinic. 


-ATALOGUE    OF  MEDICAL    WORKS. 


*  AN  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  THE  EYE, 
EAR,  NOSE,  AND  THROAT.    Edited  by  Geokge  E.  de  Sen weinitz, 

A.  M.,  M.  D.,  Professor  of  Ophthalmology,  Jefferson  Medical  College;  and 

B.  Alexander  Randall,  A.  M.,  M.  D.,  Clinical  Professor  of  Diseases  of 
the  Ear,  University  of  Pennsylvania.  One  handsome  imperial  octavo 
volume  of  1251  pages;  766  illustrations,  59  of  them  colored.  Prices: 
Clotu,  S7.00  net;  Sheep  or  Half-Morocco,  ^8.00  net. 

dust  Issued, 

The  present  work  is  the  only  book  ever  published  embracmg  diseases  of  the 
intimately  related  organs  of  the  eye,  ear,  nose,  and  throat.  Its  special  claim 
to  favor  is  based  on  encyclopedic,  authoritative,  and  practical  treatment  ol  the 
subjects. 

Each  section  of  the  book  has  been  entrusted  to  avi  author  who  is  specially 
identified  with  the  subject  on  which  he  writes,  and  who  therefore  presents  his 
case  in  the  manner  of  an  expert.  Uniformity  is  secured  and  overlapping  pre- 
vented by  careful  editing  and  by  a  system  of  cross-references  which  forms  a 
special  feature  of  the  volume,  enabling  the  reader  to  come  into  touch  with  all 
that  is  said  on  any  subject  in  different  portions  of  the  book. 

Particular  emphasis  is  laid  on  the  most  approved  methods  of  treatment,  so 
that  the  book  shall  be  one  to  which  the  student  and  practitioner  can  refer  for 
information  in  practical  work.  Anatomical  and  physiological  problems,  also, 
are  fully  discussed  for  the  benefit  of  those  who  desire  to  investigate  the  more 
abstruse  problems  of  the  subiect. 


€0?rTRIBUTOBS  : 


Dr.  Henry  A.  Alderton,  Brooklyn.  i 

Harrison  Allen,  Philadelphia.  j 

F'.ank  All  port,  Chicago,  1 

Morris  J.  Asch,  New  York.  I 

S.  C.  Ayres,  Cincinnati.  i 

R.  O.  Beard,  Minneapolis.  j 

Clarence  J.  Blake,  Boston. 
Arthur  A.  Bliss,  Philadelphia. 
Albert  P.  Brubaker,  Philadelphia. 
J.  H.  Bryan,  Washington,  D.  C. 
A.lbert  H.  Buck,  New  York. 
F.  Buller,  Montreal,  Can. 
Swan  M.  Burnett,  Washington,  D   C. 
^'lemming  Carrow,  Ann  Arbor,  Mich. 
W.  E.  Casselberry,  Chicago. 
Colman  W.  Cutler,  New  York. 
Edward  B.  Dench,  New  York. 
William  S.  Dennett,  New  York. 
George  E.  de  Schweinitz,  Philadelphia. 
Alexander  Duane,  New  York. 
John  W.  Farlow,  Boston,  Mass. 
Walter  J.  Freeman,  Philadelphia. 
H.  Gifford,  Omaha,  Neb. 
W.  C.  Glasgow,  St.  Louis. 
J.  Orne  Green,  Boston. 
Ward  A.  Holden,  New  York.. 
Christian  R.  Holmes,  Cincinnati. 
William  E.  Hopkins,  San  Francisco. 
F.  C.  Hotz,  Chicago. 
Lucien  Howe,  Buffalo,  N.  Y.  j 


Dr.  Alvin  A.  Hubbell,  Buffalo,  W.  Y. 
Edward  Jackson,  Philadelphia, 
j.  Ellis  Jennings,  St.  Louis. 
Herman  Knapp,  New  York. 
Cha^.  W.  Kollock,  Charleston,  S.  C- 
G.  A.  Leland,  Boston. 
J.  A.  LippiHCOtt,  Pittsburg,  Pa. 
G.  Hudson  Makuen,  Philadelphia. 
Tohn  H.  McCollom,  Boston. 
Vi.  G.  Miller,  Providence,  R.  L 
B.  L.  Milliken,  Cleveland,  Ohio. 
P.obert  C  Myles,  New  York. 
James  E.  Newcomb,  New  York. 
R.  J.  Phillips,  Philadelphia. 
George  A.  Piersol,  Philadelphia. 
W.  P.  Porcher,  Charleston,  S.  C. 
B.  Alex.  Randall,  Philadelphia. 
Robert  L.  Randolph,  Baltimore. 
John  O.  Roe,  Rochester,  N.  Y 
Charles  E.  de  M.  Sajous,  Philadelphia. 
J.  E.  Sheppard,  Brooklyn,  N.  Y. 
E.  L.  Shurly,  Detroit,  Mich. 
William  M.  Sweet,  Philadelphia. 
Samuel  Theobald.  Baltimore,  Md. 
A.  G.  Thomson,  Philadelphia. 
Clarence  A.  Veasey,  Philadelphia. 
John  E.  Weeks,  New  York. 
Casey  A.  Wood,  Chicago,  til. 
Jonathan  Wright,  Brooklyn. 
H.  V.  Wiirdemann,  Milwaukee,  Wis. 


i6 


IV.    B.   SAUNDERS' 


*  AN  AMERICAN  YEAR-BOOK  OF  MEDICINE  AND  SUR- 
GERY.  A  Yearly  Digest  of  Scientific  Progress  and  Autliuritative 
Opinion  in  all  branches  of  Medicine  and  Surgery,  drawn  from  journals, 
monographs,  and  text-books  of  the  leading  American  and  Foreign  authors 
and  investigators.  Collected  and  arranged,  with  critical  editorial  com- 
ments, by  eminent  American  specialists  and  teachers,  under  the  general 
editorial  charge  of  George  M.  Gould,  M.  D.  Volumes  for  1896,  '97, 
'98,  and  '99  each  a  handsome  imperial  octavo  volume  of  about  1200  pages. 
Prices  :  Cloth,  $6.50  net ;  Half-Morocco,  $7.50  net.  Year- Book  for  1900  in 
two  octavo  volumes  of  about  600  pages  each.  Prices  per  volume :  Cloth, 
;^3.oo  net;  Half- Morocco,  $3.75  net. 

In  Two  Volumes.     No  Increase  in  Price, 

In  response  to  a  widespread  demand  from  the  medical  jirofession,  the  pub- 
lisher of  the  "American  Year-Book  of  Medicine  and  Surgery"  has  decided  to 
issue  that  well-known  work  in  two  volumes,  Vol.  I.  treating  of  General  Medi- 
cine, Vol.  II.  of  General  Surgery.  Each  volume  is  complete  in  itself,  and 
the  work  is  sold  either  separately  or  in  sets. 

This  division  is  made  in  such  a  way  as  to  appeal  to  physicians  from  a  class 
standpoint,  one  volume  being  distinctly  medical,  and  the  other  distinctly  surgi- 
cal. This  arrangement  has  a  two-fold  advantage.  To  the  physician  who  uses 
the  entire  book,  it  offers  an  increased  amount  of  matter  in  the  most  convenient 
form  for  easy  consultation,  and  without  any  increase  in  price ;  while  the  man 
who  wants  either  the  medical  or  the  surgical  section  alone  secures  the  com])lete 
consideration  of  his  branch  without  the  necessity  of  purchasing  matter  for  which 

he  has  no  use. 

CONTRIBUTORS : 


Vol.  I. 
Dr.  Samuel  W,  Abbolt,  Boston. 
Archibald  Church,  Chicago. 
Louis  A.  Duhring,  Philadelphia. 
D.  L.  Edsall,  Philadelphia. 
Alfred  Hand,  Jr.,  Philadelphia. 
M.  B.  Hartzell,  Philadelphia. 
Reid  Hunt,  Baltimore. 
Wyatt  Johnston,  Montreal. 
Walter  Jones,  Baltimore. 
David  Riesman.  Philadelphia. 
Louis  Starr,  Philadelphia.  _ 
Alfred  Stengel,  Philadelphia. 
A.  A.  Stevens,  Philadelphia. 
G.  N.  Stewart.  Cleveland. 
Reynold  W.  Wilcox,  New  York  City. 


Vol.  n. 
Dr.  J    Montgomery  Baldy,  Philadelphia. 
Charles  H.  Burnett,  Philadelphia. 
J.  Chalmers  DaCosta.  Philadelphia. 
W.  A.    N.  Dorland,  Philadelphia. 
Virgil  P.  Gibney,  New  York  City. 
C.  H.  Haniann,  Cleveland. 
Howard  F.  Hansell,  Philadelphia. 
Barton  Cooke  Hirst,  Philadelphia. 
E.  Fletcher  Ingals,  Chicago. 
W.  W.  Keen,  Philadelphia. 
Henry  G.  Ohls,  Chicago. 
Wendell  Reber,  Philadelphia. 
J.  Hilton  Waterman,  New  York  City. 


"It  is  difficult  to  know  which  to  admire  most— the  research  and  industry  of  tne  distin- 
guished band  of  experts  whom  Dr.  Gould  has  enlisted  in  the  service  of  the  Year-Book,  or  the 
wealth  and  abundance  of  the  contributions  to  every  department  of  science  that  have  been 
deemed  worthy  of  analysis.  ...  It  is  much  more  than  a  mere  compilation  of  abstracts,  for, 
as  each  section  is  entrusted  to  experienced  and  able  contributors,  the  reader  has  the  advan- 
tage of  certain  critical  commentaries  and  expositions  .  .  .  proceedmg  from  writers  fully 
qualified  to  perform  these  tasks.  ...  It  is  emphatically  a  book  which  should  find  a  place  in 
every  medical  library,  and  is  in  several  respects  more  useful  than  the  famous  '  Jahrbucher 
of  Germany." — Londoti  Lancet. 


CATALOGUE    OF  MEDICAL    WORKS.  ly 

*  ANOMALIES  AND  CURIOSITIES  OF  MEDICINE.    By  George 

M.  Gould,  M.D.,  and  Waltkr  L.  Pyle,  M.D.  An  encyclopedic  collec- 
tion of  are  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an  ex- 
haustive research  of  medical  literature  from  its  origin  to  the  present  day, 
abstracted,  classified,  annotated,  and  indexed.  Handsoiiie  imperial  octavo 
volume  of  968  pages,  with  295  engravings  in  the  text,  and  12  full-page 
plates.     Cloth,  ^3.00  net ;  Half-Morocco,  $4.00  net. 

POPULAR  EDITION  REDUCED  FROM  $6.00  to  $3.00. 

In  view  of  the  greatsuccess  of  this  magnificent  work,  the  publisher  has  decided 
to  issue  a  "  Popular  Edition  "  at  a  price  so  low  that  it  may  be  procured  by  every 
student  and  practitioner  of  medicine.  Notwithstanding  the  great  reduction  in 
price,  there  will  be  no  depreciation  in  the  excellence  of  typography,  paper,  and 
binding  that  characterized  the  earlier  editions. 

Several  years  of  exhaustive  research  have  been  spent  by  the  authors  in  the 
great  medical  libraries  of  the  United  States  and  Europe  in  collecting  the  mate- 
rial for  this  work.  Medical  literature  of  all  ages  and  all  languages  has 
been  carefully  searched,  as  a  glance  at  the  Bibliographic  Index  will  show.  The 
facts,  which  will  be  of  extreme  value  to  the  author  and  lecturer,  have  been 
arranged  and  annotated,  and  full  reference  footnotes  given. 

"One  of  the  most  valuable  contributions  ever  made  to  medical  literature.  It  is,  so  far  as 
we  know,  absolutely  unique,  and  every  page  is  as  fascinating  as  a  novel.  Not  alone  for  the 
medical  profession  has  this  volume  value  :  it  will  serve  as  a  book  of  reference  for  all  who  are 
interested  in  general  scientific,  sociologic,  or  medico-legal  topics." — Brooklyn  Medical  jfour- 
nal. 

NERVOUS  AND  MENTAL  DISEASES.  By  Archibald  Church, 
M.  D.,  Professor  of  Clinical  Neurology,  Mental  Diseases,  and  Medical 
Jurisprudence,  Northwestern  University  Medical  School ;  and  Frederick 
Peterson,  M.  D.,  Clinical  Professor  of  Mental  Diseases,  Woman's  Medi- 
cal College,  New  York.  Handsome  octavo  volume  of  843  pages,  with 
over  300  illustrations.  Prices:  Cloth,  ^5.00  net;  Half-Morocco,  ^6.00 
net. 

Second  Edition. 

This  book  is  intended  to  furnish  students  and  practitioners  with  a  practical, 
working  knowledge  of  nervous  and  mental  diseases.  Written  by  men  of  wide 
experience  and  authority,  it  presents  the  many  recent  additions  to  the  subject. 
The  book  is  not  tilled  with  an  extended  dissertation  on  anatomy  and  pathology, 
but,  treating  these  points  in  connection  with  special  conditions,  it  lays  particular 
stress  on  methods  of  examination,  diagnosis,  and  treatment.  In  this  respect  the 
work  is  unusually  complete  and  valuable,  laying  down  the  definite  courses  of 
procedure  which  the  authors  have  found  to  be  most  generally  satisfactory. 

"  The  vforV.  is  an  epitome  of  what  is  to-day  known  of  nervous  diseases  prepared  for  the 
student  and  practitioner  in  the  light  of  the  author's  experience  .  .  .  We  believe  that  no  work 
presents  the  difficult  subject  of  insanity  in  such  a  reasonable  and  readable  way." — Chicago 
Medical  Recorder, 


1 8  PV.    B.    SAUJ^  DENS' 


DISEASES  OF  THE  NOSE  AND  THROAT.  By  D.  Bradkn  Kyle. 
•  M.  D.,  Clinical  Professor  of  Laryngology  and  Rlunology,  Jefferson  Medi- 
cal College,  Philadelphia;  Consulting  Laryngologist,  Rhinologist,  and 
Otologist,  St.  Agnes'  Hospital.  Octavo  volume  of  646  pages,  with  over 
150  illustrations  and  6  lithographic  plates.  Cloth,  ^4.00  net;  Half-Mo- 
rocco, ^5.00  net. 

tTust  Issued. 

This  book  presents  the  subject  of  Diseases  of  the  Nose  and  Throat  '.n  as  con- 
cise a  manner  as  is  consistent  with  clearness,  keeping  in  mind  the  needs  of  the 
student  and  general  practitioner  as  well  as  those  of  the  specialist.  The  arrange- 
ment and  classilication  are  based  on  modern  pathology,  and  the  pathological 
views  advanceil  are  supported  by  drawings  of  microscopical  sections  made  in  the 
author's  own  laboratory.  These  and  the  other  illustrations  are  particularly  fine, 
lieing  chiefly  original.  With  the  practical  purpose  of  the  book  in  mind,  ex- 
tended consideration  has  been  given  to  details  of  treatment,  each  disease  being 
considered  in  full,  and  delinite  courses  being  laid  down  to  meet  special  condi- 
tions and  symptoms. 

"  Itisa  thorough,  full,  and  systematic  tre.itise,  so  classified  and  arranged  as  greatly  to  facili- 
tate the  teachina;  of  laryngology  and  rhinology  to  classes,  and  must  prove  most  convenient 
and  satisfactory  as  a  reference  book,  both  for  students  and  practitioners." — International 
Medical  Magazine. 

THE  HYGIENE  OF  TRANSMISSIBLE  DISEASES  ;  their  Causa- 
tion, Modes  of  Dissemination,  and  Methods  of  Prevention.  By 
A.  C.  Abbott,  M.  D.,  Professor  of  Hygiene  in  the  University  of  Pennsyl- 
vania; Director  of  the  Laboratory  of  Hygiene.  Octavo  volume  of  311 
pages,  v/ith  charts  and  maps,  and  numerous  illustrations.     Cloth,  ^2.00  net. 


Just  Issued. 

It  is  not  the  purpose  of  this  work  to  present  the  subject  of  Hygiene  in  the 
comprehensive  sense  ordinarily  implied  by  the  word,  but  rather  to  deal  directly 
with  but  a  section,  certainly  not  the  least  important,  of  the  subject — viz.,  that 
embracing  a  knowledge  of  the  preventable  specific  diseases.  The  book  aims  to 
furnish  information  concerning  the  detailed  management  of  transmissible  dis- 
eases. Incidentally  there  are  discussed  those  numerous  and  varied  factors  that 
have  not  only  a  direct  bearing  upon  the  incidence  and  suppression  of  such  dis- 
eases, but  are  of  general  sanitary  importance  as  well. 

"  The  work  is  admirable  in  conception  and  no  less  so  in  execution.  It  is  a  practical  work, 
simply  and  lucidly  written,  and  it  should  prove  a  most  helpful  aid  in  that  department  of 
medicine  which  is  becoming  daily  of  increasing  importance  and  application — namely,  prophy- 
laxis."— l^hiladctphia  Medical  Journal. 

"  It  is  scientific,  but  not  too  technical  ;  it  is  as  complete  as  our  present-day  knowledge  of 
hygiene  and  sanitation  allows,  and  it  is  in  harmony  with  the  efforts  of  the  profession,  which 
are  tending  more  and  more  to  methods  of  prtiphylaxis.  For  the  student  and  for  the  practi- 
tioner it  is  well  nigh  indispensable." — Medical Ne-MS,  New  York. 


CATALOGUE    OF  MEDICAL    WORKS.  ig 

A  TEXT-BOOK  OF  EMBRYOLOGY.  By  John  C.  Heisler,  M.  D., 
Professor  of  Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia 
Octavo  volume  of  405  pages,  with  190  illustrations,  26  in  colors.  Cloth, 
^2.50  net. 

Just  Issued. 

The  facts  of  embryology  having  acquired  in  recent  years  such  great  interest 
in  connection  with  the  teaching  and  with  the  proper  comprehension  of  human 
anatomy,  it  is  of  first  importance  to  the  student  of  medicine  that  a  concise  and 
yet  sutficiently  full  text-book  upon  the  subject  be  available.  It  was  with  the 
aim  of  presenting  such  a  book  that  this  volume  was  written,  the  author,  in  his 
experience  as  a  teacher  of  anatomy,  having  been  impressed  with  the  fact  that 
students  were  seriously  handicapped  in  their  study  of  the  subject  of  embryology 
by  the  lack  of  a  text-book  full  enough  to  be  intelligible,  and  yet  without  that 
minuteness  of  detail  which  characterizes  the  larger  treatises,  and  which  so  often 
serves  only  to  confuse  and  discourage  the  beginner. 

"  In  short,  the  book  is  written  to  fill  a  want  which  has  distinctly  existed  and  which  it 
definitely  meets ;  commendation  greater  than  this  it  is  not  possible  to  give  to  anything." — 
Medical  News,  New  York. 

A  MANUAL  OF  DISEASES  OF  THE  EYE.  By  Edward  Jack- 
son, A.  M.,  M.  D.,  sometime  Professor  of  Diseases  of  the  Eye  in  the  Phila- 
delphia Polyclinic  and  College  for  Graduates  in  Medicine.  l2mo,  604 
pages,  with  178  illustrations  from  drawings  by  the  author.    Cloth,  ^2.50  net. 

Just  Issued. 

This  book  is  intended  to  meet  the  needs  of  the  general  practitioner  of  medi- 
cine and  the  beginner  in  ophthalmology.  More  attention  is  given  to  the  condi- 
tions that  must  be  met  and  dealt  with  early  in  ophthalmic  practice  than  to  the 
rarer  diseases  and  more  difficult  operations  that  may  come  later. 

It  is  designed  to  furnish  efficient  aid  in  the  actual  work  of  dealing  with  dis- 
ease, and  therefore  gives  the  place  of  first  importance  to  the  recognition  and 
management  of  the.  conditions  that  present  themselves  in  actual  clinical  work.    . 

LECTURES  ON  THE  PRINCIPLES  OF  SURGERY.  By  Charles 
B.  Nancrede,  M.  D.,  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
University  of  Michigan,  Ann  Arbor.  Handsome  octavo,  398  pages,  illus- 
trated.    Cloth,  ^2.50  net. 

Just  Issued. 

The  present  book  is  based  on  the  lectures  delivered  by  Dr.  Nancrede  to  his 
undergraduate  classes,  and  is  intended  as  a  text-book  for  students  and  a  practi- 
cal help  for  teachers.  By  the  careful  elimination  of  unnecessary  details  of 
pathology,  bacteriology,  etc.,  which  are  amply  provided  for  in  other  courses  of 
study,  space  is  gained  for  a  more  extended  consideration  of  the  Principles  of 
Surgery  in  themselves,  and  of  the  application  of  these  principles  to  methods 
of  practice. 


20  ^y.   B.    SAUNDERS' 


A  TEXT-BOOK  OF  PATHOLOGY.  By  Alfred  Stengel,  M.  D., 
Professor  of  Clinical  Medicine  in  the  University  of  Pennsylvania;  Physi- 
cian to  the  Philadelphia  Hospital ;  Physician  to  the  Children's  Hospital, 
Philadelphia.  Handsome  octavo  volume  of  848  pages,  with  362  illustra- 
tions, many  of  which  are  in  colors.  Prices :  Cloth,  ;^4.oo  net ;  Half- 
Morocco,  ^5.00  net. 

Second  Edition. 

In  this  work  the  practical  application  of  pathological  facts  to  clinical  medicine 
is  considered  more  fully  than  is  customary  in  works  on  ]3atliology.  While  the 
subject  of  pathology  is  treated  in  the  broadest  way  consistent  with  the  size  of 
the  book,  an  effort  has  been  made  to  present  the  sul^ject  from  the  point  of  view 
of  the  clinician.  The  general  relations  of  bacteriology  to  pathology  are  dis- 
cussed at  considerable  length,  as  the  importance  of  these  branches  deserves.  It 
will  be  found  that  the  recent  knowledge  is  fully  considered,  as  well  as  older  and 
more  widely-known  facts. 

"  I  consider  the  work  abreast  of  modern  pathology,  and  useful  to  both  students  and  prac- 
titioners. It  presents  in  a  concise  and  well-considered  form  the  essential  facts  of  general  and 
special  pathological  anatomy,  with  more  than  usual  emphasis  upon  pathological  physiology." 
— William  H.  Welch,  Professor  of  Pathology ,  fohns  Ho/>kins  University ,  Baltimore,  Md. 
"  I  regard  it  as  the  most  sers'iceable  text-book  for  students  on  this  subject  yet  written  by 
an  American  author." — L.  Hektoen,  Professor  of  Pathology,  Rush  Medical  College, 
Chicago,  III. 

A  TEXT-BOOK  OF  OBSTETRICS.  By  Barton  Cooke  Hirst,  M.D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome  oc- 
tavo volume  of  846  pages,  with  618  illustrations  and  seven  colored  plates. 
Prices:  Cloth,  ^5.00  net;  Half-Morocco,  $6.00  net. 

Second  Edition. 

This  work,  which  has  been  in  course  of  preparation  for  several  years,  is  in- 
tended as  an  ideal  text-book  for  the  student  no  less  than  an  advanced  treatise 
for  the  obstetrician  and  for  general  practitioners.  It  represents  the  very  latest 
teaching  in  the  practice  of  obstetrics  by  a  man  of  extended  experience  and 
recognized  authority.  The  book  emphasizes  especially,  as  a  work  on  obstetrics 
should,  the  practical  side  of  the  subject,  and  to  this  end  presents  an  unusually 
large  collection  of  illustrations.  A  great  number  of  these  are  new  and  original, 
and  the  whole  collection  will  form  a  complete  atlas  of  obstetrical  practice. 
An  extremely  valuable  feature  of  the  book  is  the  large  number  of  refer- 
ences to  cases,  authorities,  sources,  etc.,  forming,  as  it  does,  a  valuable  bib- 
liography of  the  most  recent  and  authoritative  literature  on  the  subject 
of  obstetrics.  As  already  stated,  this  work  records  the  wide  practical  ex- 
perience of  the  author,  which  fact,  combined  with  the  brilliant  presentation 
of  the  subject,  will  doubtless  render  this  one  of  the  most  notable  books  on 
obstetrics  that  has  yet  appeared, 

"  The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the 
first  time.  The  arrangement  of  the  subject-matter,  the  foot-notes,  and  index  are  beyond 
criticism.  The  author's  style,  though  condensed,  is  singularly  clear,  so  that  it  is  never 
necessarj'  to  re-read  a  sentence  in  order  to  grasp  its  meaning.  As  a  true  model  of  what  a 
modern  text-book  in  obstetrics  should  be,  we  feel  justified  in  affirming  that  Dr.  Hirst's 
book  is  without  a  rival." — New   York  Medical  Record. 


CATALOGUE    OF  MEDICAL    WORKS.  21 

A    TEXT-BOOK    OF    THE    PRACTICE    OF    MEDICINE.      By 

James  M.  Anders,  M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of 
Medicine  and  of  Clinical  Medicine,  Medico-Chirurgical  College,  Philadel- 
phia. In  one  handsome  octavo  volume  of  1292  pages,  fully  illustrated. 
Cloth,  ^5.50  net ;  Sheep  or  Half-Morocco,  $6.50  net. 

THIRD   EDITION,  THOROUGHLY   REVISED. 

The  present  edition  is  the  result  of  a  careful  and  thorough  revision.  A  few 
new  subjects  have  been  introduced  :  Glandular  Fever,  Ether-pneumonia,  Splenic 
Anemia,  Meralgia  Paresthetica,  and  Periodic  Paralysis.  The  affections  that 
have  been  substantially  rewritten  are:  Plague,  Malta  Fever,  Diseases  of  the 
Thymus  Gland,  Liver  Cirrhoses,  and  Progressive  Spinal  Muscular  Atrophy. 
The  following  articles  have  been  extensively  revised  :  Typhoid  Fever,  Yellow 
Fever,  Lobar  Pneumonia,  Dengue,  Tuberculosis,  Diabetes  Mellitus,  Gout,  Ar- 
thritis Deformans,  Autumnal  Catarrh,  Diseases  of  the  Circulatory  System,  more 
particularly  Hypertrophy  and  Dilatation  of  the  Heart,  Arteriosclerosis  and 
Thoracic  Aneurysm,  Pancreatic  Hemorrhage,  Jaundice,  Acute  Peritonitis,  Acute 
Yellow  Atrophy,  Hematoma  of  Dura  Mater,  and  Scleroses  of  the  Brain.  The 
preliminary  chapter  on  Nervous  Diseases  is  new,  and  deals  with  the  subject  of 
localization  and  the  various  methods  of  investigating  nervous  affections. 

"It  is  an  excellent  book — concise,  comprehensive,  thorough,  and  up  to  date.  It  is  a 
credit  to  you;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia— to  us." 
— James  C.  Wilson,  Professor  of  the  Practice  of  Medicine  and  Clinical  Medicine,  Jeffer- 
son Medical  College,  Philadelphia. 

"  The  book  can  be  unreservedly  recommended  to  students  and  practitioners  as  a  safe,  full 
compendium  of  the  knowledge  of  internal  medicine  of  the  present  day  ...  It  is  a  work 
thoroughly  modern  in  every  sense." — Medical  News,  New  York. 

DISEASES  OF  THE  STOMACH.  By  William  W.  Van  Vai.zah, 
M.  D.,  Professor  of  General  Medicine  and  Diseases  of  the  Digestive  System 
and  the  Blood,  New  York  Polyclinic;  and  J.  Douglas  Nisbet,  M.  D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive  Sys- 
tem and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674  pages, 
illustrated.     Cloth,  ^3.50  net. 

An  eminently  practical  book,  intended  as  a  guide  to  the  student,  an  aid  to  the 
physician,  and  a  contribution  to  scientific  medicine.  It  aims  to  give  a  complete 
description  of  the  modern  methods  of  diagnosis  and  treatment  of  diseases  of  the 
stomach,  and  to  reconstruct  the  pathology  of  the  stomach  in  keeping  with  the 
revelations  of  scientific  research.  The  book  is  clear,  practical,  and  complete, 
and  contains  the  results  of  the  authors'  investigations  and  of  their  extensive  ex- 
perience as  specialists.  Particular  attention  is  given  to  the  important  subject  of 
dietetic  treatment.  The  diet-lists  are  very  complete,  and  are  so  arranged  that 
selections  can  readily  be  made  to  suit  individual  cases. 

"  This  is  the  most  satisfactory  work  on  the  subject  in  the  English  language." — Chicago 
Medical  Recorder, 

"  The  article  on  diet  and  general  medication  is  one  of  the  most  valuable  in  the  book,  and 
should  be  read  by  every  practising  physician." — New  York  Medical  Journal. 


22  IV.   B.    SAUNDERS' 


SURGICAL   DIAGNOSIS    AND    TREATMENT.     By   J.  W.    Mac- 
DONAi.D,  M.  D.,  Edin.,  !•".  R.  C.  S.,  Edin.,  Professor  of  the  Practice  of  Sur- 
gery and  of  Clinical  Surgery  in  Haniline  University;  Visiting  Surgeon  to  St. 
Barnabas'  Hospital,  Minneapolis,  etc.     Handsome  octavo  volume  of  800 
pages,  profusely  illustrated.     Cloth,  $5.00  net;  Half-Morocco,  $6.00  net. 
This  work  aims  in  a  comprehensive  manner  to  furnish  a  guide  in  matters  of 
surgical  diagnosis.      It  sets  forth  in  a  systematic  way  the  necessities  of  examina- 
tions and  the  proper  methods  of  making  them.     The   various  portions  of  the 
body  are  then  taken  up  in  order  and  the  diseases  and  injuries  thereof  succinctly 
considered  and  the  treatment  briefly  indicated.      Practically  all  the  modern  and 
approved  operations  are  described  with  thoroughness  and  clearness.     The  work 
concludes  with  a  chapter  on  the  use  of  the  Rontgen  rays  in  surgery. 

"  The  work  is  brimful  of  just  the  kind  of  practical  information  that  is  useful  alike  to 
students  and  practitioners.  It  is  a  pleasure  to  commend  the  book  because  of  its  intrinsic 
value  to  the  medical  practitioner." — Cincinnati  Lancet-Clinic. 

PATHOLOGICAL  TECHNIQUE.     A  Practical  Manual  for  Laboratory 
Work  in  Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on 
Post-Mortem  Technique  and  the  Performance  of  Autopsies.     By  Frank 
B.  Mallory,  A.  M.,  M.  D.,  Assistant  Professor  of   Pathology,  Harvard 
University  Medical  School,  Boston;  and  James  H.  Wright,  A.  M.,  M.D., 
Instructor  in  Pathology,  Harvard  University  Medical  School,  Boston.     Oc- 
tavo volume  of  396  pages,  handsomely  illustrated.     Cloth,  52.50  net. 
This  book  is  designed  especially  for  practical  use  in  pathological  laboratories, 
both  as  a  guide  to  beginners  and  as  a  source  of  reference  for  the  advanced.    The 
book  will  also  meet  the  wants  of  practitioners  who  have  opportunity  to  do  general 
pathological  work.     Besides  the  methods  of  post-mortem  examinations  and  of 
bacteriological    and   histological   investigations    connected    with    autopsies,   the 
special  methods   employed  in  clinical  bacteriology  and  pathology  have  been 
fully  discussed. 

"  One  of  the  most  complete  works  on  the  subject,  and  one  which  should  be  in  the  library 
of  every  physician  who  hopes  to  keep  pace  with  the  great  advances  made  in  pathology." — 
jfournat  of  American  Medical  Association. 

THE  SURGICAL  COMPLICATIONS  AND  SEQUELS  OF  TY- 
PHOID FEVER.     By  Wm.  W.  Keen,  M.  D.,  LL.D.,  Professor  of  the 
Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College, 
Philadelphia.     Octavo  volume  of  386  pages,  illustrated.    Cloth,  ^3.00  net. 
This  monograph  is  the  only  one  in  any  language  covering  the  entire  subject 
of  the  Surgical  Complications  and  Sequels  of  Typhoid   Fever.     The  work  will 
prove  to  be  of  importance  and  interest  not  only  to  the  general  surgeon  and  phy- 
sician, but  also  to  many  s]^ecialists — laryngologists,  ophthalmologists,  gynecolo- 
gists, pathologists,  and  bacteriologists — as  the  subject  has  an  important  bearing 
upon  each  one  of  their  spheres.     The  author's  conclusions  are  based  on  reports 
of  over  1700  cases,  including  practically  all  those  recorded  in  the  last  fifty  years. 
Reports  of  cases  have  been   Iirought  down  to  date,  many  having  been  added 
while  the  work  was  in  press. 

"  This  is  probably  the  first  and  only  work  in  the  English  language  that  gives  the  reader  a 
clear  view  of  what  typhoid  fever  really  is,  and  what  it  does  and  can  do  to  the  human  organ- 
ism. This  book  should  be  in  the  possession  of  every  medical  man  in  America." — American 
Medico-Surgical  Bulletin, 


CATALOGUE    OF  MEDICAL    WORKS.  23 

MODERN  SURGERY,  GENERAL  AND  OPERATIVE.  By  John 
Chalmers  DaCosta,  M.  D.,  Professor  of  Practice  of  Surgery  and  Clin- 
ical Surgery,  Jefferson  Medical  College,  Philadelphia;  Surgeon  to  the  Phil- 
adelphia Hospital,  etc.  Handsome  octavo  volume  of  911  pages,  profusely 
illustrated.     Cloth,  ^4.00  net ;  Half-Morocco,  ^5.00  net. 

Second  Edition,  Rewritten  and  Greatly  Enlarged. 

The  remarkable  success  attending  DaCosta's  Manual  of  Surgery,  and  the 
general  favor  with  which  it  has  been  received,  have  led  the  author  in  this 
revision  to  produce  a  complete  treatise  on  modern  surgery  along  the  same  lines 
that  made  the  former  edition  so  successful.  The  book  has  been  entirely  re- 
written nnd  very  much  enlarged.  The  old  edition  has  long  been  a  favorite  not 
only  with  students  and  teachers,  but  also  with  practising  physicians  and  sur- 
geons, and  it  is  believed  that  the  present  work  will  find  an  even  wider  field  of 
usefulness. 

"  We  know  of  no  small  work  on  surgery  in  the  English  language  which  so  well  fulfils  the 
requirements  of  the  modern  student." — Medico-Chirurgical  Journal,  Bristol,  England. 

"  The  author  has  presented  concisely  and  accurately  the  principles  of  modern  surgery. 
The  book  is  a  valuable  one  which  can  be  recommended  to  students  and  is  of  great  value  to 
the  general  practitioner." — American  Jojirnal  of  the  Medical  Sciences. 

A  MANUAL  OF  ORTHOPEDIC  SURGERY.  By  James  E.  Moore, 
M.D.,  Professor  of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery, 
University  of  Minnesota,  College  of  Medicine  and  Surgeiy.  Octavo  volume 
of  356  pages,  with  177  beautiful  illustrations  from  photographs  made  spec- 
ially for  this  work.     Cloth,  ^2.50  net. 

A  practical  book  based  upon  the  author's  experience,  in  which  special  stress 

.  is  laid  upon  early  diagnosis  and  treatment  such  as  can  be  carried  out  by  the 

general  practitioner.     The  teachings  of  the  author  are  in  accordance  with  his 

belief  that  true  conservatism  is  to  be  found  in  the  middle  course  between  the 

surgeon  who  operates  too  frequently  and  the  orthopedist  who  seldom  operates. 

"A  very  demonstrative  work,  every  illustration  of  which  conveys  a  lesson.  The  work  is 
a  most  excellent  and  commendable  one,  which  we  can  certainly  endorse  with  pleasure." — 
St.  Louis  Medical  and  Surgical  Journal. 

ELEMENTARY  BANDAGING    AND    SURGICAL   DRESSING, 

With  Directions  concerning  the  Immediate  Treatment  of  Cases  of  Emer- 
gency. For  the  use  of  Dressers  and  Nurses.  By  Walter  Pye,  F.R.C.S., 
late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo,  with  over  80 
illustrations.     Cloth,  flexible  covens,  75  cents  net. 

This  little  book  is  chiefly  a  condensation  of  those  portions  of  Pye's  "  Surgical 
Handicraft"  which  deal  with  bandaging,  splinting,  etc.,  and  of  those  which 
treat  of  the  management  in  the  first  instance  of  cases  of  emergency.  The 
directions  given  are  thoroughly  practical,  and  the  book  will  prove  extremely  use- 
ful to  students,  surgical  nurses,  and  dressers. 

"The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  portable, 
although  the  paper  and  type  are  good." — British  Medical  Journal. 


24  fV.   B.   SAUNDERS' 


A    TEXT-BOOK    OF    MATERIA    MEDICA,    THERAPEUTICS 
AND  PHARMACOLOGY.     By  George  F.  Butler,  Ph.G.,  M.D., 
rrofessor  of  Materia  Medica  and  of  Clinical  Medicine  in  the  College  of 
Physicians   and    Surgeons,   Chicago;    Professor  of    Materia    Medica   and 
Therapeutics,   Northwestern    University,  Woman's    Medical    School,   etc 
Octavo,  874  pages,  illustrated.     Cloth,  $4.00  net ;  Sheep,  $5.00  net. 
Third  Edition,  Thoroughly  Revised. 
A  clear,  concise,  and  practical  text-book,  adapted  for  permanent  reference  no 
less  than  for  the  requirements  of  the  class-room. 

The  recent  important  additions  made  to  our  knowledge  of  the  physiological 
action  of  drugs  are  fully  discussed  in  the  present  edition.  The  book  has  been 
thoroughly  revised  and  many  additions  have  been  made. 

"  Taken  as  a  whole,  the  book  may  fairly  be  considered  as  one  of  the  most  satisfactory  of  any 
single-volume  works  on  materia  medica  in  the  market."— y^arwa/  <y  i/te  American  Medical 
Association . 

TUBERCULOSIS     OF     THE     GENITO-URINARY     ORGANS, 
MALE  AND  FEMALE.     By  Nicholas  Senn,  M.D.,  Ph.D.,  LL.D., 
Professor  of  the  Practice  of  Surgery  and  of  Clinical  Surgery,  Rush  Medical 
College,  Chicago.     Handsome   octavo  volume   of  320  pages,   illustrated^ 
Cloth,  $3.00  net. 
Tuberculosis   of  the  male  and  female  genito-urinary  organs  is  such  a  frequent, 
distressing,  and  fatal   affection  that  a  special  treatise  on  the  subject  appears  to 
fill  a  gap  in  medical  literature.     In  the  present  work  the  bacteriology  of  the  sub- 
ject has  received  due  attention,  the  modern  resources  employed  in  the  differen- 
tial diagnosis   between  tubercular  and    other  inflammatory  affections   are  fully 
described,  and   the  medical   and  surgical  therapeutics  are  discussed   in  detail. 

"An  important  book  upon  nn  important  subject,  and  written  by  a  man  of  mature  judg- 
ment and  wide  experience.  The  author  has  given  us  an  instructive  book  upon  one  of  the 
most  important  subjects  of  the  day." — Clinical  Reporter. 

"A  work  which  adds  another  to  the  many  obligations  the  profession  owes  the  talented 
author." — Chicago  Medical  Recorder. 

A  TEXT-BOOK  OF  DISEASES  OF  WOMEN.  By  Charles  B. 
Penrose,  M.D.,  Ph.D.,  Professor  of  Gynecology  in  the  University  of 
Pennsylvania;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Octavo 
volume  of  531  pages,  with  217  illustrations,  nearly  all  from  drawings  made 
for  this  work.     Cloth,  ^3.75  net. 

Third  Edition,  Revised, 

In  this  work,  which  has  been  written  for  both  the  student  of  gynecology  and 
the  general  practitioner,  the  author  presents  the  best  teaching  of  modern  gyne- 
cology untrammelled  by  antiquated  theories  or  methods  of  treatment.  In  most 
instances  but  one  plan  of  treatment  is  recommended,  to  avoid  confusing  the 
student  or  the  physician  who  consults  the  book  for  practical  guidance. 

"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women'  received.  I  have 
already  recommended  it  to  my  class  as  THE  BEST  book." — Howard  A.  K.v.iaj^ ,  Professor 
0/  Gynecology  and  Obstetrics,  Johtis  Hopkins  University,  Baltimore,  Md. 

"  The  book  is  to  be  commended  without  reserve,  not  only  to  the  student  but  to  the  general 
practitioner  who  wishes  to  have  the  latest  and  best  modes  of  treatment  explained  with  absolute 
clearness." —  Therapeutic  Gazette. 


CATALOGUE    OF  MEDICAL    WORKS.  25 

SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  John 
Collins  Warren,  M.D.,  LL.D.,  Professor  of  Surgery,  Medical  Depart- 
ment Harvard  University.  Handsome  octavo,  832  pages,  with  136  relief 
and  lithographic  illustrations,  2iZ  <^f  which  are  printed  in  colors. 

Second  Edition, 

with  an  Appendix  devoted  to  the  Scientific  Aids  to  Surgical  Diagnosis,  and 
a  series  of  articles  on  Regional  Bacteriology.  Cloth,  ^5.00  net;  Half- 
Morocco,  ;^6.oo  net. 

Without   Exception,  the  Illustrations    are   the  Best  ever  Seen   in   a 
Work  of  this  Kind. 

"A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without  ex- 
ception, from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work 
of  this  kind,  *  *  *  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their 
coloring  and  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the 
barrel  of  a  microscope  at  a  well-mounted  section." — Annah  of  Surgery,  Philadelphia. 

"  It  is  the  handsomest  specimen  of  book-making  *  *  *  that  has  ever  been  issued  from  the 
American  medical  press." — Ainerican  Journal  of  the  Medicai  Sciences ,  Philadelphia. 

PATHOLOGY  AND   SURGICAL  TREATMENT   OF  TUMORS. 

By  N.  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College;  Professor  of  Surgery,  Chicago 
Polyclinic ;  Attending  Surgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief, 
St.  Joseph's  Hospital,  Chicago.  One  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  New  and  enlarged  Edition 
in  Preparation. 

Books  specially  devoted  to  this  subject  are  few,  and  in  our  text-books  and 
systems  of  surgery  this  part  of  surgical  pathology  is  usually  condensed  to  a  de- 
gree incompatible  with  its  scientific  and  clinical  importance.  The  author  spent 
many  years  in  collecting  the  material  for  this  work,  and  has  taken  great  pains 
to  present  it  in  a  manner  that  should  prove  useful  as  a  text-book  for  the  student, 
a  work  of  reference  for  the  practitioner,  and  a  reliable  guide  for  the  surgeon. 

"  The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language 
for  some  years.  The  book  is  handsomely  illustrated  and  printed,  ....  and  the  author  has 
given  a  notable  and  lasting  contribution  to  surgery." — Jotirnal  of  the  American  Medical 
Association,  Chicago, 

LECTURES    ON    RENAL    AND    URINARY     DISEASES.      By 

Robert  Saundby,  M.  D.,  Edin.,  Fellow  of  the  Royal  College  of  Physicians, 
London,  and  of  the  Royal  Medico-Chirurgical  Society;  Physician  to  the 
General  Hospital.  Octavo  volume  of  434  pages,  with  numerous  illustra- 
tions and  4  colored  plates.     Cloth,  ^2.50  net. 

"The  volume  makes  a  favorable  impression  at  once.  The  style  is  clear  and  succinct. 
We  cannot  find  any  part  of  the  subject  in  which  the  views  expressed  are  not  carefully  thought 
out  and  fortified  by  evidence  drawn  from  the  most  recent  sources.  The  book  may  be  cordially 
recommended." — British  Medical  Journal. 


26  IV.   B.   SAUNDERS' 


A  HANDBOOK    FOR   NURSES.     By  J.  K.   Watson,   M.D.,   Eiiin.. 

'  Assistant  IIouse-Suigeo:i,  Shefliekl  Royal  Hospital.     American  Edition, 

under   the    supervision    of  A.  A.  Stevens,    A.  M.,   M.  D.,    Professor  of 

Pathology,  Woman's  Medical  College,  Philadelphia.     l2mo,  413  pages, 

73  illustrations.     Cloth,  $1.50  net. 

This  work  aims  to  supply  in  one  volume  that  information  which  so  many 
nurses  at  the  present  time  are  trying  to  extract  from  various  medical  works,  and 
10  present  that  information  in  a  suitable  form.  Nurses  must  necessarily  ac(|uire 
a  certain  amount  of  medical  knowledge,  and  the  author  of  this  book  has  aimed 
judiciously  to  cater  to  this  need  with  the  object  of  directing  the  nurses'  pursuit 
of  medical  information  in  proper  and  legitimate  channels.  The  book  represents 
an  entirely  new  departure  in  nursing  literature,  insomuch  as  it  contains  useful 
information  on  medical  and  surgical  matters  hitherto  only  to  be  obtained  from 
expensive  works  written  expressly  for  medical  men. 

A  NEW  PRONOUNCING  DICTIONARY  OF  MEDICINE,  with 
Phonetic  Pronunciation,  Accentuation,  Etymology,  etc.  By  John 
M.  Kkating,  M.  D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia; Etlitor  "Cyclopaedia  of  the  Diseases  of  Children,"  etc.;  and 
Henry  Hamilton,  with  the  Collaboration  of  J.  Chalmers  DaCosta, 
M.  D,,  and  FREDERICK  A.  Packard,  M.  D.  One  very  attractive  volume 
of  over  800  pages.  Second  Revised  Edition.  Prices:  Cioth,  ^5.00  net ; 
Sheep  or  Half-Morocco,  ^6.00  net;  with  Denison's  Patent  Ready- Refer- 
ence Index ;  without  patent  index.  Cloth,  $400  net ;  Sheep  or  Hali- 
Morocco,  ^5.00  net. 

PROFESSIONAI.  OPIHriOBTS. 

"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommending 
it  to  my  classes." 

Henkv  M.  Lyman,  M.  D., 
Professor  of  Principles  and  Practice  of  Medicine^  Rush  Medical  College,  Chicafco,  III. 

'  I  am  convinced  that  it  wiii  De  a  verj'  valuable  adjunct  to  my  study-table,  convenient  in 
size  and  sufficiently  full  for  ordinary  use." 

C  A.  LiNDSLEY,  M.  D., 
i-rq/essor  of  Theory  and  Practice  0/  Medicine,  Medical  Defit.  Yale  University : 

Secretary  Connecticut  State  Board  0/  Health,  Neiv  Haven.  Conn. 

AUTOBIOGRAPHY  OF  SAMUEL  D.  GROSS,  M.  D.,  Emeritus  Pro- 
fessor of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  with 
Reminiscences  of  His  Times  and  Contemporaries.  Edited  by  his  sons, 
Samuel  W.  Gross,  M.  D.,  LL.D.,  and  A.  Haller  Gross,  A.M.,  of  the 
Philadelphia  Bar.  Preceded  by  a  Memoir  of  Dr.  Gross,  by  the  late 
Austin  Flint,  M.  D.,  LL.D.  In  two  handsome  volumes,  each  containing 
over  400  pages,  demy  8vo,  extra  cloth,  gilt  tops,  with  fine  Frontispiece 
etigraved  on  steel.     Price  per  Volume,  ;^2.5o  net. 


CATALOGUE    OF  MEDICAL    WORKS.  2/ 

PRACTICAL  POINTS  IN  "NURSING.  For  Nurses  in  Private 
Practice.  By  Emily  A.  M.  Sidney,  Graduate  of  the  Training-SchooI 
lor  Nurses,  Lawrence,  Mass. ;  Superintendent  of  the  Training-School  for 
iVurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  handsomely 
illustrated  with  73  engravings  in  the  text,  and  9  colored  and  half-tone 
Dlates.     Cloth.     Price,  ti.l^  net 

SECOND  EDITION,  THOROUGHLY  REVISED, 

In  this  volume  the  author  explains,  in  popular  language  and  in  the  shortest 
possible  form,  the  entire  range  of  frivate  nursing  as  distinguished  from  hospital 
nursing,  and  the  nurse  is  instructed  how  best  to  meet  the  various  emergencies  of 
medical  and  surgical  cases  when  distant  from  medical  or  surgical  aid  or  when 
thrown  on  her  own  resources. 

t\.\\  especially  valuable  feature  of  the  -work  will  be  found  in  the  directions  to 
the  nurse  how  to  improvise  everything  ordinarily  needed  in  the  sick-room,  where 
the  embarrassment  of  the  nurse,  owing  to  the  want  of  proper  appliances,  is  fre- 
quently extreme. 

The  work  has  been  logically  divided  into  the  following  sections : 

I.  The  Nurse  :  her  responsibilities,  qualifications,  equipment,  etc. 
II.  The  Sick-Room  :  its  selection,  preparation,  and  management. 
Till.  The  Patient :  duties  of  the  nurse  in  medical,  surgical,  obstetric,  a.nd  gyne- 
cologic cases. 
IV.  Nursing  in  Accidents  and  Emergencies. 
V.  Nursing  in  Special  Medical  Cases. 
VI.  Nursing  of  the  New-born  and  Sick  Children. 
VII.  Physiology  and  Descriptive  Anatomy. 

The  Appendix  contains  much  information  m  compact  form  that  will  be  found 
of  great  value  to  the  nurse,  including  Rules  for  Feeding  the  Sick;  Recipes  for 
Invalid  Foods  and  Beverages ;  Tables  of  Weights  and  Measures ;  Table  for 
Computing  the  Date  of  Labor ;  List  of  Abbreviations ;  Dose-List ;  and  a  full 
and  complete  Glossary  of  Medical  Terms  and  Nursing  Treatment. 

"This  is  a  well-written,  eminently  practical  volume,  which  covers  the  entire  range  of 
private  nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to 
meet  the  various  emergencies  which  may  arise  and  how  to  prepare  everything  ordinarily 
needed  in  the  illness  of  her  patient." — American  Jo7ir7ial  of  Obstetrics  and  Diseases  of 
Women  and  Children,  Aue.,  i8g6. 

A  TEXT-BOOK  OF  BACTERIOLOGY,  including  the  Etiology  and 
Prevention  of  Infective  Diseases  and  an  account  of  Yeasts  and  Moulds, 
Hsemalozoa,  and  Psorosperms.  By  Edgar  M.  Crookshank,  M.  B.,  Pro- 
lessor  of  Comparative  Pathology  and  Bacteriology,  King's  College,  London. 
A  handsome  octavo  volume  of  700  pages,  with  273  engravings  in  the  text, 
and  22  original  and  colored  plates.     Price.  ^6.50  net. 

This  book,  though  nominally  a  Fourth  Edition  of  Professor  Crookshank's 
"  Manual  of  Bacteriology,"  is  practically  a  new  work,  the  old  one  having 
been  reconstructed,  greatly  enlarged,  revised  throughout,  and  largely  rewritten, 
forming  a  text-book  for  the  Bacteriological  Laboratory,  for  Medical  Ofhcers  of 
Health,  and  for  Veterinary  Insoectors. 


28  IV.  B.    SAUNDERS' 


MEDICAL  DIAGNOSIS.  By  Dr.  Oswald  Vierordt,  Professor  of 
Medicine  at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  Fifth  Enlarged  German  Edition,  with  the  author's  permission,  by 
Francis  H.  Stuart,  A.  M.,  M.  D.  In  one  handsome  royal-octavo  volume 
of  600  pages.  194  fine  wood-cuts  in  the  text,  many  of  them  in  colors. 
Prices:  Cloth,  $4.00  net;  Sheep  or  Half- Morocco,  $5.00  net. 

FOURTH  AMERICAN  EDITION,  FROM  THE  FIFTH  REVISED  AND 
ENLARGED  GERMAN  EDITION. 

In  this  work,  as  in  no  other  hitherto  published,  are  given  full  and  accurate 
explanations  of  the  phenomena  observed  at  the  bedside.  It  is  distinctly  a  clin- 
ical work  by  a  master  teacher,  characterized  by  thoroughness,  fulness,  and  accu- 
racy. It  is  a  mine  of  information  upon  the  points  that  are  so  often  passed  over 
without  explanation.  Especial  attention  has  been  given  to  the  germ-theory  as  a 
factor  in  the  origin  of  disease. 

The  present  edition  of  this  highly  successful  work  has  been  translated  from 
the  fifth  German  edition.  Many  alterations  have  been  made  throughout  the 
book,  but  especially  in  the  sections  on  Gastric  Digestion  and  the  Nervous  System. 

It  will  be  found  that  all  the  qualities  which  served  to  make  the  earlier  editions 
so  acceptable  have  been  developed  with  the  evolution  of  the  work  to  its  present 
form. 

THE  PICTORIAL  ATLAS  OF  SKIN  DISEASES  AND  SYPHI- 
LITIC AFFECTIONS.  (American  Edition.)  Translation  from 
the  French.  Edited  by  J.  J.  Pringle,  M.  B.,  F.  R.  C.  P.,  Assistant  Phy- 
sician to,  and  Physician  to  the  department  for  Diseases  of  the  Skin  at,  the 
Middlesex  Hospital,  London.  Photo-lithochromes  from  the  famous  models 
of  dermatological  and  syphilitic  cases  in  the  Museum  of  the  Saint-Louis 
Hospital,  Paris,  with  explanatory  wood-cuts  and  letter-press.  In  12  Parts, 
at  $3.00  per  Part. 

"  Of  all  the  atlases  of  skin  diseases  which  have  been  published  in  recent  years,  the  present 
one  promises  to  be  of  greatest  interest  and  value,  especially  from  the  standpoint  of  the 
general  practitioner." — American  Medico-Surgical  Bulletin,  Feb.  22,  1896. 

"The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say,  has  been  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — Neiv  York  Medical  Journal,  Feb.  15,  1896. 

"  An  interesting  feature  of  the  Atlas  is  the  descriptive  text,  which  is  written  for  each  picture 
by  the  physician  who  treated  the  ca-se  or  at  whose  instigation  the  models  have  been  made. 
We  predict  for  this  truly  beautiful  work  a  large  circulation  in  all  parts  of  the  medical  world 
where  the  names  St.  Louis  and  Baretta  have  preceded  it." — Medical  Record,  N.  Y.,  Feb.  i, 
1896. 

A  TEXT-BOOK  OF  MECHANO-THERAPY  (MASSAGE  AND 
MEDICAL  GYMNASTICS).  By  Axel  V.  Grafstrom,  B.  Sc, 
M.  D.,  late  Lieutenant  in  the  Royal  Swedish  Army;  late  House  Physi- 
cian, City  Hospital,  Blackwell's  Island,  New  York.  i2mo,  139  pages, 
illustrated.     Cloth,  ^i. 00  net. 


CATALOGUE    OF  MEDICAL    WORKS.  2g 

DISEASES  OF  THE  EYE.  A  Hand-Book  of  Ophthalmic  Prac- 
tice. By  G.  E.  DE  SCHWEINITZ,  M.  D.,  Professor  of  Ophthalmology  in 
the  Jefferson  Medical  College,  Philadelphia,  etc.  A  handsome  royal- 
octavo  volume  of  696  pages,  with  255  fine  illustrations,  many  of  which  are 
original,  and  2  chromo-lithographic  plates.  Prices :  Cloth,  ^4.00  net ; 
Sheep  or  Half-Morocco,  ^5.00  net. 

THIRD  EDITION,  THOROUGHLY  REVISED. 

In  the  third  edilion  of  this  text-book,  destined,  it  is  hoped,  to  meet  the  favor- 
able reception  which  has  been  accorded  to  its  predecessors,  the  work  has  been 
revised  thoroughly,  and  much  new  matter  has  been  introduced.  Particular 
attention  has  been  given  to  the  important  relations  which  micro-organisms  bear 
to  many  ocular  diseases.  A  number  of  special  paragraphs  on  new  subjects  have 
been  introduced,  and  certain  articles,  including  a  portion  of  the  chapter  on 
Operations,  have  been  largely  rewritten,  or  at  least  materially  changed.  A 
number  of  new  illustrations  have  been  added.  The  Appendix  contains  a  full 
description  of  the  method  of  determining  the  corneal  astigmatism  with  the 
ophthalmometer  of  Javal  and  Schiotz,  and  the  rotation  of  the  eyes  with  the 
tropometer  of  Stevens. 

"A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.     I  am  satisfied  that  unusual  success  awaits  it." 

William  Pepper,  M.  D. 
Provost  and  Professor  of  Theory  and  Practice  of  Medicine  and  Clinical  Medicine 
in  the  University  of  Pennsylvania. 

"A  clearly  written,  comprehensive  manual.  .  .  .  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering  upon 
the  study  of  this  special  branch  of  medical  science." — British  Medical  Journal. 

"  It  is  hardly  too  much  to  say  that  for  the  student  and  practitioner  beginning  the  study  of 
Ophthalmology,  it  is  the  best  single  volume  at  present  published." — Medical  News. 

"  It  is  a  very  useful,  satisfactory,  and  safe  guide  for  the  student  and  the  practitioner,  and 
one  of  the  best  works  of  this  scope  in  the  English  language." — Annals  of  Ophthalmology. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.R.  C.  S.,  Assistant 
Surgeon  to  Middlesex  Hospital,  and  Surgeon  to  Chelsea  Hospital,  London ; 
and  Arthur  E.  Giles,  M.  D.,  B.  Sc,  Lond.,  F.  R.C.  S.,  Edin.,  Assistant 
Surgeon  to  Chelsea  Hospital,  London.  436  pages,  handsomely  illustrated. 
Cloth,  ^2.50  net. 

The  authors  have  placed  in  the  hands  of  the  physician  and  student  a  concise 
yet  comprehensive  guide  to  the  study  of  gynecology  in  its  most  modern  develop- 
ment. It  has  been  their  aim  to  relate  facts  and  describe  methods  belonging  to 
the  science  and  art  of  gynecology  in  a  way  that  will  prove  useful  to  students  for 
examination  purposes,  and  which  will  also  enable  the  general  physician  to  prac- 
tice this  important  department  of  surgery  with  advantage  to  his  patients  and  with 
satisfaction  to  himself. 

"  The  book  is  very  well  prepared,  and  is  certain  to  be  well  received  by  the  medical  public." 
— British  Medical  Journal. 

"The  text  has  been  carefully  prepared.  Nothing  essential  has  been  omitted,  and  its 
teachings  are  those  recommended  by  the  leading  authorities  of  the  Aa.y."—Journal  of  the 
American  Medical  Association, 


30  m:   £.   SAUNDEk^'^ 


TEXT-BOOK  UPON  THE  PATHOGENIC  BACTERIA,  bpt-.- 
cially  written  for  Students  of  Medicine.  By  Joseph  McFarland. 
M.  D.,  Professor  of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical 
College  of  Philadelphia,  etc.  497  pages,  finely  illustrated.  Price,  Cloth, 
52.50  net. 

SECOND  EDITION,  REVISED  AND  GREATLY  ENLARGED. 
The  work  is  intended  to  be  a  text-book  for  tlic  medical  student  and  for  the 
practitioner  who  has  had  no  recent  laboratory  training  \\\  this  department  of  medi- 
cal science.  Tlie  instructions  given  as  to  needed  ai)])aratus,  cultures,  stainings, 
microscopic  examinations,  etc.  are  ample  for  the  student's  needs,  and  will  aflbrd 
to  the  physician  much  information  that  will  interest  and  prolit  him  relative  to  a 
subject  which  modern  science  shows  to  go  far  in  explaining  the  etiology  ot  many 
diseased  conditions. 

In  this  second  edition  the  work  has  been  brought  up  to  date  in  all  depart- 
ments of  the  subject,  and  numerous  additions  have  been  made  to  the  technique 
in  the  endeavor  to  make  the  book  fulfil  the  double  purpose  of  a  systematic  work 
upon  bacteria  and  a  laboratory  guiae. 

"  It  is  excellently  adapted  for  the  medical  students  and  practitioners  for  whom  it  is  avowedly 
written.  .  .  .  The  descriptions  given  are  accurate  and  readable,  and  the  book  should  prove 
useful  to  those  for  whom  it  is  written. — London  Lancet,  Aug.  29,  1891). 

"  The  author  has  sncceded  admirably  in  presenting  the  essential  details  of  bacteriological 
technics,  together  with  a  judiciously  chosen  summary  of  our  present  knowledge  of  pathogenic 
bacteria.  .  .  .  The  work,  we  think,  should  have  a  wide  circulation  among  English-speaking 
students  of  medicine." — N.  Y.  Medical  Journal,  April  4,  1896. 

"  The  book  will  be  found  of  considerable  use  by  medical  men  who  have  not  had  a  special 
bacteriological  training,  and  who  desire  to  understand  this  important  branch  of  medical 
science." — Edinburgh  Medical  Journal,  July,  i8y£. 

LABORATORY    GUIDE    FOR    THE    BACTERIOLOGIST.      By 

Langdon  Frothingham,  M.  D.  V.,  Assistant  in  Bacteriology  and  Veteri- 
nary Science,  Sheffield  Scientific  School.  Yale  University.  Illustrated. 
Price,  Clotn,  75  cents. 

The  technical  methods  involved  in  bacteria-culture,  methods  of  staining,  ana 
microscopical  study  are  fully  described  and  arranged  as  simply  and  concisely  as 
possible.     The  book  is  especially  intended  for  use  in  laboratory  woric 

"  It  is  a  convenient  and  useful  little  work,  and  will  more  than  repay  the  outlay  necessary 
for  its  purchase  in  the  saving  of  time  which  would  otherwise  be  consumed  in  looking  up  trie 
various  points  of  technique  so  clearly  and  concisely  laid  down  in  its  pages." — Jinierican  ikea.- 
Surg.  Bulleiin. 

FEEDING  IN  EARLY  INFANCY.  By  Arthur  V.  Meigs,  M.  D. 
Bound  in  limp  cloth;  flush  edges.     Price,  25  cents  net. 

Synopsis  :  Analyses  of  Milk — Importance  of  the  Subject  of  Feeding  in  Early 
Infancy — Proportion  of  Casein  and  Sugar  in  Human  Milk — Time  to  Begin  Arti- 
ficial Feeding  of  Infants — Amount  of  Food  to  be  Administered  at  Each  Feed- 
ing— Intervals  between  Feedings — Increase  in  Amount  of  Food  at  Different 
Periods  of  Infant  Development — Unsuitableness  of  Condensed  Milk  as  a  Sub- 
stitute for  Mother's  Milk — Objections  to  Sterilization  or  "  Pasteurization  "  erf 
Milk — Advances  made  in  the  Method  of  Artificial  Feeding  of  Infants. 


CATALOGUE    OF  MEDICAL    WORKS.  3I 

MATERIA    MEDICA    FOR    NURSES.     By  Emily    A.   M,   Stoney, 

Graduate  of  the  Training-school  for  Nurses,  Lawrence,  Mass. ;  late 
Superintendent  of  the  Training-school  for  Nurses,  Carney  Ilosijital,  South 
Boston,  Mass.     Handsome  octavo,  300  pages.     Cloth,  ^1.50  net. 

The  present  book  differs  from  other  similar  works  in  several  features,  all  of 
which  are  introduced  to  render  it  more  practical  and  generally  useful.  The 
general  plan  of  contents  follows  the  lines  laid  down  in  training-schools  for 
nurses,  but  the  book  contains  much  useful  matter  not  usually  included  in  works 
of  this  character,  such  as  Poison-emergencies,  Ready  Dose-list,  Weights  and 
Measures,  etc.,  as  well  as  a  Glossary,  defining  all  the  terms  in  Materia  Medica, 
and  describing  all  the  latest  drugs  and  remedies,  which  have  been  generally 
neglected  by  other  books  of  the  kind. 

ESSENTIALS    OF   ANATOMY  AND    MANUAL  OF    PRACTI"^ 

CAL  DISSECTION,  containing  "  Hints  on  Dissection."  By  Charle.s 
B.  Nancrede,  M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in  the 
University  of  Michigan,  Ann  Arbor ;  Corresponding  Member  of  the  Royal 
Academy  of  Medicine,  Rome,  Italy;  late  Surgeon  Jefferson  Medical  Col- 
lege, etc.  Fourth  and  revised  edition.  lost  8vo,  over  500  pages,  with 
handsome  full -page  lithographic  plates  in  colors,  and  over  200  illustrations. 
Price  :  Extra  Cloth  or  Oilcloth  for  the  dissection-room,  ^2.00  net. 

Neither  pains  nor  expense  nas  been  spared  to  make  this  work  the  most  ex- 
haustive yet  concise  Student's  Manual  of  Anatomy  and  Dissection  ever  pub- 
lished, either  in  America  or  in  Europe. 

The  colored  plates  are  designed  to  aid  the  student  in  dissecting  the  muscles 
arteries,  veins,  and  nerves.  The  wood-cuts  have  all  been  specially  drawn  ancj 
engraved,  and  an  Appendix  added  containing  60  illustrations  representing  the 
structure  of  the  entire  human  skeleton,  the  whole  being  based  on  the  eleventh 
edition  of  Gray's  Anatomy^ 

A  MANUAL  OF  PRACTICE  OF  MEDICINE.  By  A.  A.  Stevens, 
A.  M.,  M.  D.,  Instructor  in  Physical  Diagnosis  in  the  University  of  Penn- 
sylvania, and  Professor  of  Pathology  in  the  Woman's  Medical  College  of 
Pennsylvania.  Specially  intended  for  students  preparing  for  graduation 
and  hospital  examinations.  Post  8vo,  519  pages.  Numerous  illustrations 
and  selected  formulae.     Price,  bound  in  flexible  leather,  ^2.00  net. 

FIFTH  EDITION,  REVISED  AND  ENLARGED. 

Contributions  to  tlie  science  ot  medicine  have  poured  in  so  rapidly  during  the 
last  quarter  of  a  century  that  it  is  well-nigh  impossible  for  the  student,  with  the 
limited  time  at  his  disposal,  to  master  elaborate  treatises  or  to  cull  from  them 
that  knowledge  which  is  absolutely  essential.  From  an  extended  experience  m 
teaching,  the  author  has  been  enabled,  by  classification,  to  group  allied  symp- 
toms, and  by  the  judicious  elimination  of  theories  and  redundant  explanations 
to  brmg  vvithir.  r.  '""mDaratively  small  compass  a  complete  outline  of  the  prac« 
tice  ot  medicme. 


32  IV.   B.   SAUNDERS 


MANUAL    OF    MATERIA    MEDICA    AND    THERAPEUTICS. 

By  A.  A.  Stevens,  A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the 
University  of  Pennsylvania,  and  Professor  of  Pathology  in  the  Woman's 
Medical  College  of  Pennsylvania.  445  pages.  Price,  bound  in  flexible 
leather,  $2.25. 

SECOND  EDITION,    REVISED. 

This  wholly  new  volume,  which  is  based  on  the  last  edition  of  the  Pharma- 
copoeia, comprehends  the  following  sections :  Physiological  Action  of  Drugs ; 
Drugs;  Remedial  Measures  other  than  Drugs;  Applied  Therapeutics;  Incom- 
patibility in  Prescriptions;  Table  of  Doses;  Index  of  Drugs;  and  Index  of 
Diseases;  the  treatment  being  elucidated  by  more  than  two  hundred  formulae. 

"  The  author  is  to  be  congratulated  upon  having  presented  the  medical  student  with  as 
accurate  a  manual  of  therapeutics  as  it  is  possible  to  prepare." —  Tlierapeutic  Gazette. 

"  Far  superior  to  most  of  its  class ;  in  fact,  it  is  very  good.  Moreover,  the  book  is  reliable 
and  accurate." — A^e^u  York  Medical  Journal. 

"  The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work,  .  .  . 
and  it  will  be  found  a  reliable  guide." —  University  Medical  Magazine. 

NOTES  ON  THE  NEWER  REMEDIES:  their  Therapeutic  Ap- 
plications and  Modes  of  Administration.  By  David  Cerna,  M.  D., 
Ph.  D.,  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in 
the  University  of  Pennsylvania.     Post-octavo,  253  pages.     Price,  j?l.25. 

SECOND  EDITION,  RE-WRITTEN  AND  GREATLY  ENLARGED. 

The  work  takes  up  in  alphabetical  order  all  the  newer  remedies,  giving  their 
physical  properties,  solubility,  therapeutic  applications,  administration,  and 
chemical  formula. 

It  thus  forms  a  very  valuable  addition  to  the  various  works  on  therapeutics 
now  in  existence. 

Chemists  are  so  multiplying  compounds,  that,  if  each  compound  is  to  be  thor- 
oughly studied,  investigations  must  be  carried  far  enough  to  determine  the  prac- 
tical importance  of  the  new  agents. 

"Especially  valuable  because  of  its  completeness,  its  accuracy,  its  systematic  consider- 
ation of  the  properties  and  therapy  of  many  remedies  of  which  doctors  generally  know  but 
little,  expressed  in  a  brief  yet  terse  manner." — Chicago  Clinical  Review. 


TEMPERATURE   CHART.     Prepared  by  D.  T.  Laine,  M.  D.      Size 
8x  13^  inches.     Price,  per  pad  of  25  charts,  50  cents. 

A  conveniently  arranged  chart  for  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Remarks,  etc.  On  the 
back  of  each  chart  is  given  in  full  the  method  of  Brand  in  the  treatment  of 
Typhoid  Fever. 


CATALOGUE    OF  MEDICAL    WORKS.  33 

A  TEXT-BOOK  OF  HISTOLOGY,  DESCRIPTIVE  AND  PRAC- 
TICAL. For  the  Use  of  Students.  By  Arthur  Ci.akkson,  M.  B., 
C.  M.,  Edin.,  formerly  Demonstrator  of  Physiology  iii  the  Owen's  College, 
Manchester;  late  Demonstrator  of  Physiology  in  the  Yorkshire  College, 
Leeds.  Large  8vo,  554  pages,  with  22  engravings  in  the  text,  and  174 
beautifully  colored  original  illustrations.  Price,  strongly  bound  in  Cloth, 
$4.00  net. 

The  purpose  of  the  writer  in  this  work  has  been  to  furnish  the  student  of  His- 
tology, in  one  volume,  with  both  the  descriptive  and  the  practical  part  of  the 
science.  The  first  two  chapters  are  devoted  to  the  consideration  of  the  general 
methods  of  Histology ;  subsequently,  in  each  chapter,  the  structure  of  the  tissue 
or  organ  is  first  systematically  described,  the  student  is  then  taken  tutorially  over 
the  specimens  illustrating  it,  and,  finally,  an  appendix  affords  a  short  note  of  the 
methods  of  preparation. 

"  The  work  must  be  considered  a  valuable  addition  to  the  list  of  available  text-books,  and 
is  to  be  highly  recommended." — New  York  Medical  Journal. 

"  One  of  the  best  works  for  students  we  have  ever  noticed.  We  predict  that  the  book  will 
attain  a  well-deserved  popularity  among  our  students." — Chicago  Medical  Recorder. 

THE  PATHOLOGY  AND  TREATMENT  OF  SEXUAL  IM- 
POTENCE. By  Victor  G.  Vecki,  M.  D.  '  From  the  second  Ger- 
man edition,  revised  and  rewritten.  Demi-octavo,  about  300  pages. 
Cloth,  ^2.00  net. 

The  subject  of  impotence  has  but  seldom  been  treated  in  this  country  in  the 
truly  scientific  spirit  that  it  deserves,  and  this  volume  will  come  to  many  as  a 
revelation  of  the  possibilities  of  therapeusis  in  this  important  field.  Dr.  Vetki's 
work  has  long  been  favorably  known,  and  the  German  book  has  received  the 
highest  consideration.  This  edition  is  more  than  a  mere  translation,  for,  although 
based  on  the  German  edition,  it  has  been  entirely  rewritten  by  the  author  in 
English. 

"  The  work  can  be  recommended  as  a  scholarly  treatise  on  its  subject,  and  it  can  be  read 
with  advantage  by  many  practitioners,"— yo?<r««/  of  the  American  Medical  Association. 

THE  TREATMENT  OF  PELVIC  INFLAMMATIONS 
THROUGH  THE  VAGINA.  By  W.  R.  Pryor,  M.  D.,  Pro- 
fessor of  Gynecology  in  the  New  York  Polycliiiic.  i2mo,  248  pages, 
handsomely  illustrated.     Cloth,  |2.oo  net. 

In  this  book  the  author  directs  the  attention  of  the  general  practitioner  to  a 
surgical  treatment  of  the  pelvic  diseases  of  women.  There  exists  the  utmost 
confusion  in  the  profession  regarding  the  most  successful  methods  of  treating 
pelvic  inflammations  ;  and  inasmuch  as  inflammatory  lesions  constitute  the  ma- 
jority of  all  pelvic  diseases,  the  subject  is  an  important  one.  It  has  been  the 
endeavor  of  the  author  to  put  down  every  little  detail,  no  matter  how  insig- 
nificant, which  might  be  of  service. 


34  '  PF.   B.   SAUNDERS' 


DISEASES  OF  WOMEN.  By  Henry  J.  Garrigues,  A.M.,  M.  D., 
Professur  of  Gynecology  in  the  New  York  Scliool  of  Clinical  Medicine; 
Gynecologist  to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New  ' 
York  City.  In  one  handsome  octavo  volume  of  728  pages,  illustrated  by 
335  engravings  and  colored  plates.  Prices:  Cloth,  ^4.00  net;  Sheep  or 
Half-Morocco,  ^5.00  net. 

A  PRACTICAL  work  on  gynecology  for  the  use  of  students  and  practitioners, 
written  in  a  terse  and  concise  manner.  The  importance  of  a  thorough  know- 
ledge of  the  anatomy  of  the  female  pelvic  organs  has  been  fully  recognized  by 
the  author,  and  considerable  space  has  been  devoted  to  the  subject.  The  chap- 
ters on  Operations  and  on  Treatment  are  thoroughly  modern,  and  are  based 
upon  the  large  hospital  and  private  practice  of  the  author.  The  text  is  eluci- 
dated by  a  large  number  of  illustrations  and  colored  plates,  many  of  them  being 
original,  and  forming  a  complete  atlas  for  studying  embryology  and  the  anatomy 
of  \)\Q.  female  genitalia,  besides  exemplifying,  whenever  needed,  morbid  condi« 
tions,  instruments,  apparatus,  and  operations. 

Second  Edition,  Thoroughly  Revised. 

The  first  edition  of  this  work  rnet  with  a  most  appreciative  reception  by  the 
medical  press  and  profession  both  in  this  country  and  abroad,  and  was  adopted 
as  a  text-book  or  recommended  as  a  book  of  reference  by  nearly  one  /ittndred 
colleges  in  the  United  States  and  Canada.  The  author  has  availed  himself  of 
the  opportunity  afforded  by  this  revision  to  embody  the  latest  approved  advances 
in  the  treatment  employed  in  this  important  branch  of  Medicine.  He  has  also 
more  extensively  expressed  his  own  opinion  on  the  comparative  value  of  the 
different  methods  of  treatment  employed. 

"One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Yoiuig  practitioners,  to  whom  experienced  consultants 
may  not  be  available,  will  find  in  this  book  invaluable  counsel  and  help." 

Thad.  a.  Reamy,  M.  D.,  LL.D., 
Prq/essar  of  Clinical  Gynecology,  Medical  College  of  Ohio  ;  Gynecologist  to  the  Good 
Samaritan  and  Cincinnati  Hospitals. 


A  SYLLABUS  OF  GYNECOLOGY,  arranged  in  conformity  with 
"An  American  Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Vir- 
ginia, etc.     Price,  Cloth  (interleaved),  ^i.oo  net. 

Based  upon  the  teaching  and  methods  laid  down  in  the  larger  work,  this  will 
not  only  be  useful  as  a  supplementary  volume,  but  to  those  who  do  not  already 
posses?  the  text-book  it  will  also  have  an  independent  value  as  an  aid  to  the 
practitioner  in  gynecological  work,  and  to  the  student  as  a  guide  in  the  lecture- 
room,  as  the  subject  is  presented  in  a  manner  at  once  systematic,  clear,  succinct, 
pod  practical. 


CATALOGUE   OF  MEDICAL    WORKS.  35 

THE  AMERICAN  POCKET  MEDICAL  DICTIONARY.  Edited 
by  W.  A.  Newman  Borland,  M.  D.,  Assistant  Obstetrician  to  the  Hospital 
of  the  University  of  Pennsylvania;  Fellow  of  the  American  Academy  of 
Medicine.  Containing  the  pronunciation  and  definition  of  all  the  principal 
words  used  in  medicine  and  the  kindred  sciences,  with  64  extensive  tables. 
Handsomely  bound  in  flexible  leather,  limp,  with  gold  edges  and  patent 
thumb  index.     Price,  ;^l.oo  net ;  with  thumb  index,  ^1.25  net. 

SECOND  EDITION,  REVISED. 

This  is  the  ideal  pocket  lexicon.  It  is  an  absolutely  new  book,  and  not  a  re- 
vision of  any  old  work.  It  is  complete,  defining  all  the  terms  of  modern  medi- 
cine and  forming  an  unusually  complete  vocabulary.  It  gives  the  pronunciation 
of  all  the  terms.  It  makes  a  special  feature  of  the  newer  words  neglected  by 
other  dictionaries.  It  contains  a  wealth  of  anatomical  tables  of  special  value  to 
students.     It  forms  a  handy  volume,  indispensable  to  every  medical  man. 

SAUNDERS'  POCKET  MEDICAL    FORMULARY.     By  William 

M.  Powell,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women  at  Atlantic  City.  Containing  1800  Formulae,  selected  from  several 
hundred  of  the  best-known  authorities.  Forming  a  handsome  and  con- 
venient pocket  companion  of  nearly  300  printed  pages,  with  blank  leaves 
for  Additions ;  with  an  Appendix  containing  Posological  Table,  Formulse 
and  Doses  for  Hypodermatic  Medication,  Poisons  and  their  Antidotes, 
Diameters  of  the  Pemale  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet 
List  for  Various  Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery, 
Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables 
of  Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Hand- 
somely bound  in  morocco,  with  side  index,  wallet,  and  flap.  Price,  ^1.75 
net. 

FIFTH  EDITION,  THOROUGHLY  REVISED. 

"  This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and  as  the  name  of  the  author  of  each  prescription  is 
giveUjis  unusually  reliable." — New  York  Medical  Record. 

A  COMPENDIUM  OF  INSANITY.  By  John  B.  Chapin,  M.D.,  LL.D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane;  late  Physician- 
Superintendent  ofthe  Willard  State  Hospital,  New  York ;  Honorary  Mem- 
ber of  the  Medico-Psychological  Society  of  Great  Britain,  of  the  Society  of 
Mental  Medicine  of  Belgium.     l2mo,  234  pages,  illust.     Cloth,  ^1.25  net. 

The  author  has  given,  in  a  condensed  and  concise  form,  a  compendium  of 
Diseases  of  the  Mind,  for  the  convenient  use  and  aid  of  physicians  and  students. 
It  contains  a  clear,  concise  statement  of  the  clinical  aspects  of  the  various  ab- 
normal mental  conditions,  with  directions  as  to  the  most  approved  methods  of 
managing  and  treating  the  insane. 

"  The  practical  parts  of  Dr.  Chapin's  book  are  what  constitute  its  distinctive  merit.  We 
desire  especially,  however,  to  call  attention  to  the  fact  that  in  the  subject  of  the  therapeutics 
of  insanity  the  work  is  exceedingly  valuable.  The  author  has  made  a  distinct  addition  to  the 
literature  of  his  specialty." — Philadelphia  Medical  Journal. 


36  ty.  B.   SAUNDERS' 


AN    OPERATION    BLANK,  with    Lists   of   Instruments,  etc.   re- 
,  quired  in   Various   Operations.     Prepared  by  W.  W.  Kp;en,  M.  D., 
LL.D.,  Professor  of  Principles  of  Surgery  in  the  Jefferson  Medical  Col- 
lege, Philadelphia.     Price  per  Pad,  containing  Blanks  for  fifty  operations, 
50  cents  net. 

SECOND  EDITION,  REVISED  FORM. 

A  convenient  blank,  suitable  for  all  operations,  giving  complete  instructions 
regarding  necessary  preparation  of  patient,  etc.,  with  a  full  list  of  dressings  and 
medicines  to  be  employed. 

On  the  back  of  each  blank  is  a  list  of  instruments  used — viz.  general  instru 
ments,  etc.,  required  for  all  operations ;  and  special  instruments  for  surgery  of 
the  brain  and  spine,  mouth  and  throat,  abdomen,  rectum,  male  and  female 
genito-urinary  organs,  the  bones,  etc. 

The  whole  forming  a  neat  pad,  ananged  for  hanging  on  the  wall  of  a  sur- 
geon's office  or  in  the  hospital  operating-room. 

"  Will  serve  a  useful  purpose  for  the  surgeon  in  reminding  him  of  the  details  of  prepa- 
ration for  the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antiseptics 
needed  " — Netu  York  Medical  Record 

"  Covers  about  all  that  can  be  needed  in  any  operation." — American  Lancet. 

"  The  plan  is  a  capital  one." — Boston  Medical  and  Surgical  Journal. 

LABORATORY  EXERCISES  IN  BOTANY.  By  Edson  S.  Bastin, 
M.  A.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  Col- 
lege of  Pharmacy.  Octavo  volume  of  536  pages,  87  full-page  plates.  Price, 
Cloth,  ^2.50. 

This  work  is  intended  for  the  beginner  and  the  advanced  student,  and  it  fully 
covers  the  structure  of  flowering  plants,  roots,  ordinary  stems,  rhizomes,  tubers, 
bulbs,  leaves,  flowers,  fruits,  and  seeds.  Parlicular  attention  is  given  to  the  gross 
and  microscopical  structure  of  plants,  and  to  those  used  in  medicine.  Illustra- 
tions have  freely  been  used  to  elucidate  the  text,  and  a  complete  index  to  facil- 
itate reference  has  been  added. 

"  There  is  no  work  like  it  in  the  pharmaceutical  or  botanical  literature  of  this  country,  and 
we  predict  for  it  a  wide  circulation." — American  yournal  of  Pharmacy. 

DIET  IN  SICKNESS  AND  IN  HEALTH.  By  Mrs.  Ernest  Hart, 
formerly  Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London 
School  of  Medicine  for  Women ;  with  an  Introduction  by  Sir  Henry 
Thompson,  F.  R.  C.  S.,  M.  D.,  London.  220  pages;  illustrated.  Price, 
Cloth,  $1.50. 

Useful  to  those  who  have  to  nurse,  feed,  and  prescribe  for  the  sick.  In 
each  case  the  accepted  causation  of  the  disease  and  the  reasons  for  the  special 
diet  prescribed  are  briefly  described.  Medical  men  will  find  the  dietaries  and 
recipes  practically  useful,  and  likely  to  save  ihem  trouble  in  directing  the  dietetic 
treatment  of  patients. 


CATALOGUE    OF  MEDICAL    WORKS.  37 

A  MANUAL    OF    PHYSIOLOGY,  with   Practical    Exercises.     For 

Students  and  Practitioners.    By  G.  N.  Stewart,  M.  A.,  M.  D.,  D.  Sc, 

lately  Examiner  in  Physiology,  University  of  Aberdeen,  and  of  the  New 

Museums,  Cambridge  University ;  Professor  of  Physiology  in  the  Western 

Reserve  University,  Cleveland,  Ohio.     Handsome  octavo  volume  of  848 

pages,  with  300  illustrations  in  the  text,  and  5  colored  plates.    Price,  Cloth, 

^3.75  net. 

THIRD  EDITION,  REVISED. 

"  It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deserves  to  do  so.  It  is  one  oj 
the  very  best  English  text-books  on  the  subject." — London  Lancet. 

"  Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so  nearly 
conies  up  to  the  ideal  as  does  Professor  Stewart's  volume." — British  Medical  Journal. 

ESSENTIALS  OF  PHYSICAL  DIAGNOSIS  OF  THE  THORAX. 

By  Arthur  M.  Corwin,  A.  M.,  M.  D.,  Demonstrator  of  Physical  Diagno- 
sis in  the  Rush  Medical  College,  Chicago;  Attending  Physician  to  the 
Central  Free  Dispensary,  Department  of  Rhinology,  Laryngology,  and 
Diseases  of  the  Chest.  219  pages.  Illustrated.  Cloth,  flexible  covers. 
Price,  $1.25  net. 

THIRD  EDITION,  THOROUGHLY  REVISED  AND  ENLARGED. 
SYLLABUS  OF  OBSTETRICAL  LECTURES  in  the  Medical 
Department,  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.  M.,  M.  D.,  Lecturer  on  Clinical  and  Operative  Obstetrics,  University 
of  Pennsylvania.  Third  edition,  thoroughly  revised  and  enlarged.  Crown 
8vo.     Price,  Cloth,  interleaved  for  notes,  ^2.00  net. 

"  This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in  call- 
ing attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner.  The  author  has  introduced  a 
number  of  valuable  hints  which  would  only  occur  to  one  who  was  himself  an  experienced 
teacher  of  obstetrics.  The  subject-matter  is  clear,  forcible,  and  modern.  We  are  especially 
pleased  with  the  portion  devoted  to  the  practical  duties  of  the  accoucheur,  care  of  the  child, 
etc.  The  paragraphs  on  antiseptics  are  admirable;  there  is  no  doubtful  tone  in  the  direc- 
tions given.  No  details  are  regarded  as  unimportant;  no  minor  matters  omitted.  We  ven- 
ture to  say  that  even  the  old  practitioner  will  find  useful  hints  in  this  direction  which  he  can- 
not afford  to  despise." — Neiv  York  Medical  Record. 

A  SYLLABUS  OF  LECTURES  ON  THE  PRACTICE  OF  SUR- 
GERY, arranged  in  conformity  with  «' An  American  Text-Book 
of  Surgery."  By  N.  Senn,  M.  D.,  Ph.  D.,  Professor  of  Surgery  in  Rush 
Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic.     Price,  ;^2.00. 

This  work  by  so  eminent  an  author,  himself  one  of  the  contributors  to 
"  An  American  Text-Book  of  Surgery,"  will  prove  of  exceptional  value  to 
the  advanced  student  who  has  adopted  that  work  as  his  text-book.  It  is  not 
only  the  syllabus  of  an  unrivalled  course  of  surgical  practice,  but  it  is  also  an 
epitome  of  or  supplement  to  the  larger  work. 

"  The  author  has  evidently  spared  no  pains  in  making  his  Syllabus  thoroughly  comprehen- 
sive, and  has  added  new  matter  and  alluded  to  the  most  recent  authors  and  operations.  Full 
references  are  also  given  to  all  requisite  details  of  surgical  anatomy  and  pathology."— .SriVff* 
Medical  Journal,  London. 


38  W.   B.   SAUNDERS' 


THE  CARE  OF  THE  BABY.  By  J.  P.  Crozer  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania; 
Physician  to  the  Children's  Hospital,  Philadelphia,  etc.  404  pages,  with 
67  illustrations  in  the  text,  and  5  phitcs.      i2mo.     Price,  $l.So. 

SECOND  EDITION,  REVISED. 

A  reliable  guide  not  only  for  mothers,  but  also  for  medical  students  and 
practitioners  whose  opportunities  for  observing  children  have  been  limited. 

"  The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a  mas. 
ter  hand.  It  can  be  read  with  benefit  not  only  by  mothers,  but  by  medical  students  and  by 
any  practitioners  who  have  not  had  large  opportunities  for  observing  chWdrtn."— American 
jfournal  of  Obstetrics. 

THE  NURSE'S  DICTIONARY  of  Medical  Terms  and  Nursing 
Treatment,  containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms,  Abbreviations,  and  Physiological  Names,  and  Descriptions  of  the 
Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations,  Foods, 
Appliances,  etc.  encountered  in  the  ward  or  the  sick-room.  By  Honnor 
Morten,  author  of  "  How  to  Become  a  Nurse,"  "  Sketches  of  Hospital 
Life,"  etc.     i6mo,  140  pages.     Price,  Cloth,  ^i.oo. 

This  little  volume  is  intended  for  use  merely  as  a  small  reference-book  which 
can  be  consulted  at  the  bedside  or  in  the  ward.  It  gives  sufiRcient  explanation 
to  the  nurse  to  enable  her  to  comprehend  a  case  until  she  has  leisure  to  look  up 
larger  and  fuller  works  on  the  subject. 

DIET  LISTS  AND  SICK-ROOM  DIETARY.  By  Jerome  B.  Thomas, 
M.  D.,  Visiting  Physicia-n  to  the  Home  for  Friendless  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings 
County  Hospital;  Assistant  Bacteriologist,  Brooklyn  Health  Department. 
Price,  Cloth,  ;S!l.50    (Send  for  specimen  List.) 

One  hundred  and  sixty  detachable  (perforated)  diet  lists  for  Albuminuria, 
Anaemia  and  Debility,  Constipation,  Diabetes,  Diarrhoea,  Dyspepsia,  Fevers, 
Gout  or  Uric- Acid  Diathesis,  Obesity,  and  Tuberculosis.  Also  forty  detachable 
sheets  of  Sick-Room  Dietary,  containing  full  instructions  for  preparation  of 
easily-digested  foods  necessary  for  invalids.  Each  list  is  numbered  only,  the 
disease  for  which  it  is  to  be  used  in  no  case  being  mentioned,  an  index  key 
being  reserved  for  the  physician's  private  use. 

DIETS  FOR  INFANTS  AND  CHILDREN  IN  HEALTH  AND 
IN  DISEASE.  By  Louis  Starr,  M.  D.,  Editor  of  "An  American 
Text-Book  of  the  Diseases  of  Children."  230  blanks  (pocket-book  size), 
perforated  and  neatly  bound  in  flexible  morocco.     Price,  $1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant 
life;  each  blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food, 
the  latter  directions  being  left  for  the  physician.  After  the  seventh  month, 
modifications  being  less  necessary,  the  diet  lists  are  printed  in  full.  Formula 
im  tne  preparation  of  diluents  and  foods  are  appended. 


CATALOGUE   OF  MEDICAL    WORKS.  39 


HOW  TO  EXAMINE  FOR  LIFE  INSURANCE.  By  John  M. 
Keating,  M.  D.,  Fellow  of  the  College  of  Physicians  and  Surgeons  of 
Philadelphia;  Vice-President  of  the  American  Psediatric  vSociety;  Ex- 
President  of  the  Association  of  Life  Insurance  Medical  Directors.  Royal 
8vo,  211  pages,  with  two  large  half-tone  illustrations,  and  a  plate  prepared 
by  Dr.  McClellan  from  special  dissections ;  also,  numerous  cuts  to  elucidate 
the  text.     Third  edition.      Price,  Cloth,  ^2.00  net. 

"  This  is  by  far  the  most  useful  book  v/hich  has  yet  appeared  on  insurance  examination,  a 
subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  uf  the  volume  is 
Part  II.,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four 
representative  companies  of  this  country.  As  the  proofs  of  these  instructions  were  corrected 
by  the  directors  of  the  companies,  they  form  the  latest  instructions  obtainable.  If  for  these 
alone,  the  book  should  be  at  the  right  hand  of  every  physician  interMtcd  in  this  special  branch 
of  medical  science." — -The  Medical  News,  Philadelphia. 

NURSING:    ITS    PRINCIPLES   AND    PRACTICE.      By   Isabel 

Adams  Hampton,  Graduate  of  the  New  York  Training  School  for 
Nurses  attached  to  Bellevue  Hospital;  Superintendent  of  Nurses  and 
Principal  of  the  Training  School  for  Nurses,  Johns  Hopkins  Hospital, 
Baltimore,  Md. ;  late  Superintendent  of  Nurses,  Illinois  Training  School 
for  Nurses,  Chicago,  111.  In  one  very  handsome  i2mo  volume  of  512 
pages,  illustrated.     Price,  Cloth,  ^2.00  net. 

SECOND   EDITION,  REVISED  AND  ENLARGED. 

This  original  work  on  the  important  subject  of  nursing  is  at  once  comprehensive 
and  systematic.  It  is  written  in  a  clear,  accurate,  and  readable  style,  suitable 
alike  to  the  student  and  the  lay  reader.  Such  a  work  has  long  been  a  desidera- 
tum with  those  entrusted  with  the  management  of  hospitals  and  the  instruction  of 
nurses  in  training-schools.  It  is  also  of  especial  value  to  the  graduated  nurse 
who  desires  to  acquire  a  practical  working  knowledge  of  the  care  of  the  sick 
and  the  hygiene  of  the  sick-room. 

OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND  OPERA- 
TIONS. By  L.  Ch.  Boisliniere,  M.  D.,  late  Emeritus  Professor  of 
Obstetrics  in  the  St.  Louis  Medical  College.  381  pages,  handsomely  illus- 
trated.    Price,  ^2.00  net. 

,  "  For  the  use  of  the  practitioner  who,  when  away  from  home,  has  not  the 
opportunity  of  consulting  a  library  or  of  calling  a  friend  in  consultation.  He 
then,  being  thrown  upon  his  own  resources,  will  find  this  book  of  benefit  in 
guiding  and  assisting  him  in  emergencies." 

INFANT'S  WEIGHT  CHART,  Designed  by  J.  P.  Crozer  Grjffzth, 
M.  D.,  Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Peniv 
sylvania.    25  charts  in  each  pad.     Price  per  pad,  50  cents  net. 

A  convenient  blank  for  keeping  a  record  of  the  child's  weight  during  the  first 
two  years  of  life.  Printed  on  each  chart  is  a  curve  repi'esenting  the  average  weight 
of  a  healthy  infant,  so  that  any  deviation  from  the  normal  can  readily  be  detected. 


Saunders' 
New  Series 
OF  Manuals 


for  Students 
and 
Practitioners. 


THAT  there  exists  a  need  for  thoroughly  reliable  hand-books  on  the  leading 
branches  of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the 
favor  with  which  the  SAUNDERS  NEW  SERIES  OF  MANUALS  have  been 
received  by  medical  students  and  practitioners  and  by  the  Medical  Press. 
These  manuals  are  not  merely  condensations  from  present  literature,  but 
are  ably  written  by  well-known  authors  and  practitioners,  most  of  them  being 
teachers  in  representative  American  colleges.  Each  volume  is  concisely  and 
authoritatively  written  and  exhaustive  in  detail,  without  being  encumbered 
with  the  introduction  of  "  cases,"  which  so  largely  expand  the  ordinary  text- 
book. These  manuals  will  therefore  form  an  admirable  collection  of  advanced 
lectures,  useful  alike  to  the  medical  student  and  the  practitioner :  to  the  latter, 
too  busy  to  search  through  page  after  page  of  elaborate  treatises  for  what  he 
wants  to  know,  they  will  prove  of  inestimable  value  ;  to  the  former  they  will 
afford  safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  OK  MANUALS  are  conceded  to  be 
superior  to  any  similar  books  now  on  the  market.  No  other  manuals  afford  so 
much  information  in  such  a  concise  and  available  form.  A  liberal  expenditure 
has  enabled  the  publisher  to  render  the  mechanical  portion  of  the  work  worthy 
of  the  high  literary  standard  attained  by  these  books. 

Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see  next  page 
for  List). 


SAUNDERS'  NEW  SERIES  OF  MANUALS. 


VOLUMES  PUBLISHED. 


PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.  M  ,  M.  D.,  Professor 
of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long 
Island  College   Hospital,  etc.     Price,  ^1.25  net. 

SURGERY,  General  and  Operative.  By  John  Chalmers  DaCosta, 
M.D.,  Professor  of  Practice  of  Surgery  and  Clinical  Surgery,  Jefferson 
Medical  College,  Philadelphia.  Second  edition,  revised  and  greatly  en- 
larged. Octavo,  911  pages,  386  illustrations.  Cloth,  ^4.00  net;  Half- 
Morocco,  ^5.00  net. 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION-WRITING. 

By  E.  Q.  Thornton,    M.  D.,  Demonstrator  of  Therapeutics,  Jefferson 
Medical  College,  Philadelphia.     Price,  ^1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.  D.,  Pro- 
fessor of  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jeffer- 
son Medical  College  of  Philadelphia,  etc      Price,  ^1.50  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's 
Hospital  and  to  the  German  Poliklinik ;  Instructor  in  Surgery,  New  York 
Post-Graduate  Medical  School,  etc.     Price,  ^1.25  net. 

MANUAL  OF  ANATOMY.  By  Irving  S.  Haynes,  M.D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department 
of  the  New  York  University,  etc.     Price,  S2.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James 
Nevins  Hyde,  M.D.,  Professor  of  Skin  and  Venereal  Diseases,  and 
Frank  H.  Montgomery,  M.  D.,  Lecturer  on  Dermatology  and  Genito- 
urinary Diseases  in  Rush  Medical  College,  Chicago.     Price,  $2.50  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.  D., 
Professor  of  Practice  in  the  Woman's  Medical  College  of  the  Nevir  York 
Infirmaiy,  etc.     Price,  ^2.50  net. 

OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.D.,  Assistant  Demon- 
strator of  Obstetrics,  University  of  Pennsylvania;  Chief  of  Gynecological 
Dispensary,  Pennsylvania  Hospital.     Price,  ^2.50  net. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.  R.  C.  S.,  Assistant 
Surgeon  to  the  Middlesex  Hospital,  and  Surgeon  to  the  Chelsea  Hospital 
for  Women,  London ;  and  Arthur  E.  Giles,  M.  D.,  B.  Sc.  Lond.,  F.  R.  C.  S. 
Edin.,  Assistant  Surgeon  to  the  Chelsea  Hospital  for  Women,  London.  436 
pages,  handsomely  illustrated.     Price,  ^2.50  net. 

IN    PREPARATION. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.  D.,  Clinical  Profes- 
sor of  Nervous  Diseases,  Medico-Chirurgical  College,  Philadelphia,  etc. 

***  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully  prepared  works 
on  various  subjects,  by  prominent  specialists. 


SAUNDERS'  QUESTION  COMPENDS. 

Amuiged  in  Qiiestiou  and  Answer  Form. 

THE  LATEST,  MOST  COMPLETE,  and  BEST  ILLUSTRATED 
SERIES  OF  COMPENDS  EVER  ISSUED. 


Now  the  Standard  Authorities  in  Medical  Literature 


students  and  Practitioners  in  every  City  of  the  United 
States  and  Canada. 


THE   REASON   WHY. 

They  are  the  advance  guard  of  "  Student's  Helps  " — that  DO  help;  they  are 
the  leaders  in  their  special  line,  well  and  authoritatively  wj-itten  by  able  men, 
who,  as  teachers  in  the  large  colleges,  knozv  exactly  what  is  wanted  by  a  student 
preparing  for  his  examinations.  The  judgment  exercised  in  the  selection  of 
authors  is  fully  demonstrated  by  their  professional  elevation.  Chosen  from  the 
ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of  them  have  be- 
come Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250 
pages,  profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on 
fine  paper. 

The  entire  series,  numbering  tvventy.four  subjects,  has  been  kept  thoroughly 
revised  and  enlarged  when  necessary,  many  of  them  being  in  their  fourth  and 
fifth  editions. 

TO    SUM    UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  mar- 
ket, none  of  them  approach  the  "  Blue  Series  of  Question  Compends;"  and 
the  claim  is  made  for  the  following  points  of  excellence : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Size  of  type  and  quality  of  paper  and  binding. 

%*  Any  of  these  Compends  will  be  mailed  on  receipt  of  price  (see  next 

page  for  List). 

42 


SAUNDERS*  QUESTION-COMPEND  SERIES. 


Price,  Cloth,  $J.OO  per  copy,  except  when  otherwise  noted. 

1.  ESSENTIALS  OF  PHYSIOLOGY.   4th  edition.    Illustrated.    Revised  and  enlarged. 

By  H.  A.  Hare,  M.  D.     (Price,  JSloo  net.) 

2.  ESSENTIALS  OF  SURGERY.    7th  editfon,  with  a  chapter  on  Appendicitis,    go  illus- 

trations.   By  Edward  Martin,  M.  D.  (Price,  ;jSi.oo  net ) 

3.  ESSENTIALS  OF  ANATOMY.     6th  edition,  thoroughly  revised,     i.si  illustrations. 

By  Charles  B.  Nancrede,  M.  D.     (Price,  $1.00  net.) 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

5th  edition,  revised,  with  an  Appendix.     By  Lawrence,  Wolff,  M.  D.     (^i.oo  net.) 

5.  ESSENTIALS  OF  OBSTETRICS.     4th  edition,  revised  and  enlarged.     75  illustra- 

tions.    By  W.  Easterly  Ashton,  M.  D. 

6.  ESSENTIALS  OF  PATHOLOGY  AND- MORBID  ANATOMY.     7th  thousand. 

46  illustrations.     By  C.  E.  Armand  Semple,  M.  D. 

7.  ESSENTIALS    OF    MATERIA     MEDICA,    THERAPEUTICS,    AND    PRE. 

SCRIPTION-WRITING.      5th  edition.     By  Henry  Morris,  M.  D. 

8.  g.  ESSENTIALS  OF  PRACTICE     OF    MEDICINE.      By  Henry  Morris,  M.  D. 

An  Appendix  on  Urine  Examin  ation.  Illustrated.  By  Lawrence  Wolff,  M.  D. 
3d  edition,  enlarged  by  some  300  Essential  Formulae,  selected  from  eminent  authori- 
ties, by  Wm.  M.  Powell,  M.  D.     (Double  number,  price  J2.00.) 

10.  ESSENTIALS  OF  GYN.ffiCOLOGY.     4th  edition,  revised.     With  62  illustrations. 

By  Edwin  B.  Cragin,  M.  D. 

11.  ESSENTIALS  OF  DISEASES  OF    THE  SKIN.  4th  edition,  revised  and  enlarged. 

71  letter-press  cuts  and  15  half-tone  illustrations.  By  Henry  W.  Stelwagon,  M.D. 
(Price,  $1.00  net.) 

12.  ESSENTIALS  OF  MINOR    SURGERY,  BANDAGING,  AND  VENEREAL 

DISEASES.  2d  edition,  revised  and  enlarged.  78  illustrations.  By  Edward 
Martin,  M.  D. 

13.  ESSENTIALS  OF  LEGAL    MEDICINE,  TOXICOLOGY,  AND   HYGIENE. 

130  illustrations.     By  C.  E.   Armand  Semple,  M.  D. 

14.  ESSENTIALS  OF  DISEASES  OF   THE  EYE,  NOSE,  AND  THROAT.    124 

illustrations.  2d  edition,  revised.  By  Edward  Jackson,  M.  D.,  and  E.  Baldwin 
Glkason,  M.  D. 

15.  ESSENTIALS  OF   DISEASES  OF  CHILDREN,     ad  edition.     By  William  M 

Powell,  M.  D. 

16.  ESSENTIALS  OF  EXAMINATION    OF    URINE.      Colored   " Vogel  Scale," 

and  numerous  illustrations.      By   Lawrence  Wolff,  M.D.     (Price,  75  cents.) 

17.  ESSENTIALS  OF  DIAGNOSIS.     2d  edition,  thoroughly  revised.     60  illustrations. 

By  S.  SoLis-CoHEN,  M.  D.,  and  A.  A.  Eshner,  M.  D.     (Price,  ^i.oo  net.) 

i8.  ESSENTIALS  OF  PRACTICE  OF  PHARMACY.     2d  edition,  revised.     By  L. 
E.  Sayre. 

20.  ESSENTIALS  OF  BACTERIOLOGY.     3d   edition.     82   illustrations.     By  M.  V. 

Ball,  M.D. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY.   48  illustrations. 

3d  edition,  revised.     By  John  C.  Shaw,  M.  D. 

22.  ESSENTIALS  OF  MEDICAL  PHYSICS.     155  illustrations.     2d  edition,  revised. 

By  Fred  J.  Brockway,  M.  D.     (Price,  gi.oo  net.) 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.     65  illustrations.     By  David  D. 

Stewart,  M.  D.,  and  Edward  S.  Lawrance,  M.  D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE  EAR.     114  illustrations.    2d  edition,  re- 

vised and  enlarged.     By  E.  Baldwin  Gleason,  M.  D. 


Some  of  the  Books  in  Preparation  for 
Publication  during  1900. 


AMERICAN  Text=Book  of  Pa= 
thology. 

Edited  by  LuDViG  Hektoen,  M.D.,  Pro- 
fessor of  Pathology,  Rush  Medical  College, 
Chicago;  and  David  Riesman,  M.D.,  De- 
monstrator of  Pathological  Histology,  Uni- 
versity of  Pennsylvania. 

AMERICAN  Text=Bookof  Legal 
Medicine  and  Toxicology. 

Edited  by  Frederick  Peterson,  M.D., 
Chief  of  Clinic,  Nervous  Department,  College 
of  Physicians  and  Surgeons,  New  York  City; 
and  Walter  S.  Haines,  M.D.,  Professor  of 
Chemistry,  Pharmacy,  and  Toxicology,  Rush 
Medical  College,  Chicago. 

BECK— Fractures. 

By  Carl  Reck,  M.D.,  Professor  of  Surgery 
in  the  N.  Y.  School  of  Clinical  Medicine. 

BOHM,  DAVIDOFF,  and  HU= 
BER-A  Text=Bookof  Human 
Histology. 

Including    Microscopic    Technic.     liy 

Dr  a  a.  Bohm  and  Dr.  M.  von  Davidoff, 
of  the  Anatomical  Institute  of  Munich,  and 
G.  C.  Huber,M.D.,  Junior  Professor  of  Anat- 
omy and  Histology,  University  of  Michigan, 
Ann  Arbor. 

EiCHHORST— A  Text=Book  of 
the  Practice  of  Medicine. 

liy  Dr.  Hekman  Eichhorst,  Professor  of 
Special  Pathology  and  Therapeutics  and  Di- 
rector of  the  Medical  Clinic,  University  of 
Zurich.  Translated  and  edited  by  Augustus 
A.  EsHNER,  M.D  ,  Professor  of  Clinical 
Medicine  in  the  Philadelphia  Polyclinic. 

FRIEDRICH  —  Rhinology,  La= 
ryngology,  and  Otology  in 
their  Relations  to  General 
Medicine. 

By  Dr.  E.  P.  Friedrich,  of  the  Univer- 
sity of  Leipsig. 

LEVY  AND  KLEMPERER  — 
The  Elements  of  Clinical  Bac= 
teriology. 

By  Dr.  Ernst  Levy,  Professor  in  the 
University  of  Strassburg,  and  Dr.  Felix 
Klemperer,  Privat-Docent  in  the  Univer- 
sity of  Strassburg.  Translated  and  edited 
by  Augustus  A.  Eshner,  M.D.,  Professor 
of  Clinical  Medicine  in  the  Philadelphia  Poly- 
clinic.   Just  Ready.     Cloth,  ^2.50  net. 


McFARLAND— A  Text=Book  of 
Pathology. 

By  Joseph  McFarland,  M.D.,  Professor 
of  Pathology  and  Bacteriology,  Medico-Chi- 
rurgical  College,  Philadelphia. 

OGDEN  —  Clinical  Examination 
of  the  Urine. 

By  J.  Bergen  Ogdrn,  M.D.,  Assistant  in 
Chemistry,  Harvard  Medical  School. 

PYLE— A  Manual  of  Personaf 
Hygiene. 

Edited  by  Walter  L.  Pvle,  M.D.,  Assis- 
tant Surgeon  to  Wills"  Eye  Hospital,  Philada. 

SCUDDER— The  Treatment  of 
Fractures. 

By  Charles  L.  Scudder,  M.D. .Assistant 
in  Clinical  and  Operative  Surgery,  Harvard 
University. 

SENN— Practical  Surgery. 

By  Nicholas  Senn,  M.D.,  Ph.D.,  LL.D., 
Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery,  Rush  Medical  College,  Chi- 
cago. Octavo  volume  of  about  800  pages, 
profusely  illustrated. 

The  Pathology  and  Treatment 
of  Tumors. 

By  Nicholas  Senn,  M.D.,  Ph.D., LL.D., 
Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery,  Rush  Medical  College,  Chi- 
cago. A  New  and  Thoroughly  Revised  Edi- 
tion in  preparation. 

STENGEL  AND  WHITE  — The 
Blood  in  its  Clinical  and  Patho= 
logical  Relations. 

By  Alfred  Stengel,  M.D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsyl- 
vania; and  C.  Y.  White,  M.D.,  Instruc- 
tor in  Clinical  Medicine,  University  of  Penn- 
sylvania. 

STEVENS— The  Physical  Diag= 
nosis  of  Diseases  of  the  Chest. 

By  A.  A.  Stevens,  A.M.,  M.D.,  Lecturer 
on  Terminology,  and  Instructor  in  Physical 
Diagnosis,  University  of  Pennsylvania. 

STONE Y  —  Surgical  Technique 
for  Nurses. 

By  Emily  A.  M.  Stoney,  late  Superin- 
tendent of  the  Training  Schools  for  Nurses, 
Carney  Hospital,  South  Boston,  Mass. 


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